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Título

Peduncular Hallucinosis Secondary to Cyclosporine Pontine Myelinolysis

RESUMO

Case report: A 54 years- old female patient, hospitalized in our service with a diagnosis of acute myeloid leukemia, presented with vivid and complex visual hallucinations consisting mostly of her family members, but with size distortions. She had recently undergone a stem cell transplantation and was under immunosuppressive treatment with cyclosporine. She had a normal neurological exam and denied previous similar episodes of hallucinations of any kind. Her MRI showed diffuse T2 and Flair hyperintensities in pons, suggestive of osmotic demyelination syndrome. She had normal laboratory exams, including serum glucose and electrolytes levels. Due to her immunosuppressive status, CSF was also obtained for investigation of cellularity, biochemistry, cultures, VDRL, Xpert MTB/RIF and viral PCRs (HSV 1 and 2, EBV, HIV). The results were unremarkable. There was no history of ethillism or other metabolic disorder that could result in the MRI findings. Three days before the onset of symptoms her serum cyclosporine level was supratherapeutic. Therefore, the hypothesis of an osmotic demyelination syndrome induced by cyclosporine intoxication was made. Our patient had an atypical presentation, due to the lack of motor, cerebellar or cranial nerve involvement, but presenting only with complex visual hallucinations, compatible with peduncular hallucinosis. After a change in her immunosuppressive therapy and cyclosporine discontinuation, the patient evolved with progressive improvement of symptoms.
Discussion: Peduncular hallucinosis (PH) is a rare clinical syndrome with dream-like visual hallucinations intruding normal consciousness, most commonly occurring after a midbrain or diencephalic lesion. The pathogenesis is explained by a disconnection between the ascending reticular activating system and retinogeniculocalcarine pathways, particularly at the level of the thalamus. PH occurs mostly after ischaemic infarction and tumoral lesions. Its occurrence after a imunossupressor induced osmotic demyelination syndrome is rare, with very few cases reported until now.
Final Conclusion: Complex visual hallucinations in an immunocompromised patient have a broad differential diagnosis and may require multiple complementary exams. We describe a case of PH secondary to cyclosporine-related pontine myelinolysis, which is potentially reversible with rapid identification and discontinuation of the drug.

Palavras Chave

Peduncular Hallucinosis