Acute delirious mania as a clinical state was first described over a century ago, yet it is often unrecognized in clinical practice. Typically, the presence of delirium has most often been viewed as organic rather than functional in origin. Three recent cases illustrate the rather dramatic presentation, course, and treatment of such patients. While most often diagnosed as having acute psychotic episodes of organic delirium, these patients generally meet the criteria for a diagnosis of mania with attendant delirium and respond to the standard treatments for mania. Lack of recognition of delirious mania can lead to mismanagement of the short- and long-term courses of the illness.