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Received Sep 4, 2017; Accepted Jan 18, 2018
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1. Introduction
A hallucination is the perception of an object or an event in the absence of an external stimulus. Visual hallucinations can be categorized as simple—lights, colors, or shapes—or complex with objects and people [1]. Causes include psychosis, drugs, delirium, Charles Bonnet syndrome, compressive tumors, migraines, and hypnagogic phenomena [2]. A unifying feature of these hallucinations is that they occur when the patient’s eyes are open. A review of the literature shows that cases of closed-eye hallucinations have been reported in postoperative patients who received general anesthesia or rarely in temporal lobe epilepsy [3]. The patient in this case had not received any drugs known to be hallucinogenic and did not have history of seizures or any evidence of seizure during hospitalization.
Hyponatremia can be defined as a serum sodium concentration less than 135 mEq/L. This is a known cause of neurologic symptoms, typically at levels below 120 mEq/L. Of patients with serum sodium less than 120 mEq/L, 0.5% report hallucinations [4]. However, this is the first reported case of visual hallucinations occurring exclusively with eye closure secondary to hyponatremia. It is critical to recognize these visualizations as a correctable symptom of an electrolyte abnormality.
2. Case Description
An 80-year-old male with hypertension and coronary artery disease presented with a three-day history of emesis and diarrhea, diagnosed as gastroenteritis. He endorsed dizziness and weakness but did not report any headache, blurry vision, paresthesias, or syncope. The patient also described a three-day history of complex visualizations involving a moving car. The car had color and appeared life-like. It was not distorted and seemed to be driving in a realistic manner in front of him. This occurred exclusive when his eyes were closed and immediately resolved upon opening his eyes. It was present for the majority of the time his eyes were closed and made it difficult for him to sleep.
He denied any prior hallucinations and had insight that the car was not real....