Significantly Delayed Clinical Presentation of Benzodiazepine Withdrawal: A Case Report

The patient is a 54 year old male, with past medical history of Hypertension and Bipolar I Disorder, who presented involuntarily to the psychiatric inpatient unit due to acute manic symptoms, including hyper verbosity, with fast, pressured speech and a flight of ideas, requiring frequent redirection upon interview. The patient reported regular outpatient follow-up and compliance with home medication regime (valproic acid 500mg twice daily and quetiapine 100mg daily and 300mg nightly). Urine toxicology was positive for cocaine, amphetamines, opiates, and benzodiazepine upon admission. The patient (falsely) reported daily use of 2mg alprazolam for the past five years. The patient’s home medications were initiated and he was placed on a brief alprazolam taper, with no signs of benzodiazepine withdrawal noted. Eight days after hospital presentation, an acute and severe onset of agitation, disorientation, tremoring, and gait imbalance was noted, with a disorganized and illogical thought process. The patient was noted to be actively responding to tactile hallucinations, stating that there were birds crawling on his lower extremities. Autonomic instability with tachycardia was noted. Alprazolam 2mg was immediately administered intramuscularly with minimal improvement. Diazepam 10mg every 4 hours with as needed alprazolam was initiated. Within one day, the patient exhibited immediate and drastic improvement. As per collateral, the patient was taking at least 8mg of alprazolam daily for many years. In this poster, we discuss a significantly delayed clinical presentation of benzodiazepine withdrawal due to underreported use of alprazolam and resultant inadequate maintenance and withdrawal prevention.