A Diagnostic Dilemma: Persistent Fever in a Hospitalized Patient With Alcohol Use Disorder and Pneumonia

Hospitalized patients with alcohol use disorder (AUD) frequently pose diagnostic and therapeutic challenges due to the interplay of substance use, withdrawal, and coexisting medical conditions. This case presents a 49-year-old man with a history of chronic alcohol overuse and previous alcohol withdrawal seizures, admitted for a right middle lobe pneumonia. Initial management included empiric antibiotics, hydration, and nutritional supplementation. He was also placed on symptom-triggered benzodiazepine therapy, guided by the Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) protocol, to manage alcohol withdrawal. Despite the broad-spectrum antibiotic coverage, the patient continued to experience fever and tachycardia, raising concerns about an atypical infectious process versus the manifestation of severe alcohol withdrawal. Further consideration and evaluation ruled out antibiotic-resistant organisms, pneumonia-related complications, and alternative infections such as urinary tract infection, meningitis, and endocarditis. Blood cultures taken on admission remained persistently negative, and procalcitonin levels were significantly down-trending, indicating the resolution of a bacterial infectious etiology. By hospital day 3, the patient began exhibiting agitation, shakiness, and confusion, along with persistent spikes in temperature, heart rate, and blood pressure, raising strong suspicion for delirium tremens (DT). This necessitated escalating benzodiazepine dosage on the CIWA-Ar protocol. By hospital day 9, the patient's symptoms had largely resolved, and he was discharged with ongoing care for AUD and follow-up for a lung nodule incidentally identified on chest imaging. This case emphasizes the need for a systematic diagnostic approach to differentiate overlapping symptoms in AUD patients, particularly in the context of acute infections and withdrawal syndromes. Early recognition and aggressive management of DT are critical to prevent complications and improve outcomes in this high-risk population.