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Table of Contents    
LETTERS TO EDITOR
Year : 2017  |  Volume : 65  |  Issue : 7  |  Page : 101-103

Visualization of a musical videoclip as a manifestation of simple focal epilepsy in neurocysticercosis


1 Neurology Service, Hospital Civil de Guadalajara “Fray Antonio Alcalde”, Jalisco, México
2 Neurology Service, Hospital Civil de Guadalajara “Fray Antonio Alcalde”; Traslational Neurosciences Institute, Department of Neurosciences, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Jalisco, México

Date of Web Publication8-Mar-2017

Correspondence Address:
Ruiz_sandoval Jose
Neurology Service, Hospital Civil de Guadalajara “Fray Antonio Alcalde”, Hospital street 278, Postal Code: 44280 Guadalajara, Jalisco
México
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/neuroindia.NI_1105_16

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How to cite this article:
Ricardo MM, Yuridia RV, Juan PG, Teresita VC, Jose R. Visualization of a musical videoclip as a manifestation of simple focal epilepsy in neurocysticercosis. Neurol India 2017;65, Suppl S1:101-3

How to cite this URL:
Ricardo MM, Yuridia RV, Juan PG, Teresita VC, Jose R. Visualization of a musical videoclip as a manifestation of simple focal epilepsy in neurocysticercosis. Neurol India [serial online] 2017 [cited 2017 Mar 25];65, Suppl S1:101-3. Available from: http://www.neurologyindia.com/text.asp?2017/65/7/101/201667


Sir,

Musical hallucination (MH) is defined as an abnormal perception of music in the absence of any external acoustic stimuli. It is a phenomenon that may be associated with multiple etiological factors. These types of seizures are often encountered by otorhinolaryngologists, psychiatrists, and geriatric physicians. MH has been rarely reported by neurologists in patients with focal brainstem or cortical temporal lobe lesions.[1] Here, we report a patient who showed the presence of simultaneous, paroxysmal complex visual and auditory hallucinations that appeared to him as if he was watching a videoclip. The occurrence of this form of seizures was the manifestation of focal epilepsy secondary to the presence of neurocysticercosis (NCC). To the best of our knowledge, this clinical form of focal epilepsy has not been described.

We report a right-handed, 52-year-old man, with a history of NCC and at least two generalized tonic–clonic seizures at the age of 44 and 47 years, respectively. The patient was previously treated with albendazole at another hospital and had successful seizure control with a low dose of oxcarbazepine. At the age of 49 years, the seizure pattern changed and he began to experience persistent prodromal ear fullness that lasted for 2–3 days, followed by a musical as well as a complex visual hallucination that lasted for 3–5 minutes. The MH were characterized as having a left ear predominance and consisted of a non-identifiable, pleasant piece of relaxing, classical music that was perceived at a low volume. The patient was not musically literate; however, he could distinguish the MH as being of a nonlexical type, describing it as spiritual angelic music. The patient was interviewed once again about the seizure duration. He stressed on the occurrence of seizures for short intervals of time, lasting for approximately 2–3 minutes. However, in view of the relaxing and pleasant experience, this time was, in all likelihood, overestimated.

The patient worked as an auto-detailer and was neither a musician nor had an affinity for classical music; however, during his childhood, he often listened to classical music with his father. With regard to the complex visual component, the patient described the event as his visualizing a musical videoclip, with the apparent appearance of a non-familiar music interpreter whose gender, age, and physical appearance frequently changed. The patient would not experience a loss of consciousness, and after the event, he would have a feeling of anguish. He reported that the events would occur approximately once a month. The neurological examination was unremarkable, while an evaluation by a neurootologist, that included an audiometry study, revealed a mild traumatic hypoacusis towards the right side that was thought to be secondary to his occupational exposure as an auto detailer. Fluid-attenuated inversion recovery (FLAIR)-weighted axial magnetic resonance imaging (MRI) and gadolinium-enhanced T1-weighted axial, sagittal, and coronal images showed a NCC granuloma located in the left superior temporal gyrus, which was classified as being in the granular-nodular state [Figure 1]. This parasitic lesion was found to be located in the same region in the two MRI scans done when he had the generalised tonic clonic seizures when he was 44 and 47 years old, respectively. However, the NCC was in a different life cycle stage during the two times.
Figure 1: (a) FLAIR-weighted axial MRI. (b) Gadolinium-enhanced T1-weighted axial MRI. (c) Gadolinium-enhanced T1-weighted coronal MRI. (d) Gadolinium-enhanced T1-weighted sagittal MRI. MRI shows an NCC granuloma located in the superior gyrus of the left temporal lobe classified as being in a granular-nodular state

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The standard and sleep deprived electroencephalogram (EEG) reported epileptogenic activity described as a slow spike wave in the left temporal lobe with phase reversal in the T3–T5 derivations. The dose of oxcarbazepine was increased up to 1800 mg/day; however, there was very little improvement in the seizure frequency. Therefore, we added prednisone 1 mg/kg in a tapering dose for 3 months. This resulted in a control of his epilepsy. After tapering of prednisone, the patient occasionally reported the occurrence of episodic, limited ear fullness every 2–3 months, and sometimes, the occurrence of musical hallucinations without any visual component.

We present a patient with the paroxysmal and simultaneous occurrence of complex visual and auditory hallucinations that evoked a sensation in the patient that he was visualizing a musical videoclip. This could have been the result of the spread of epileptic activity along the optical radiations in the temporal lobe. MH is considered as a type of auditory hallucination, the content of which is often familiar and may be instrumental, vocal, or both.[2] It is established that most of these hallucinations are presented in patients with an impaired hearing and psychiatric disorders, mainly occurring in women with a mean age of over 60 years. Its pathophysiology is similar to that of the Charles Bonnet syndrome, and it is extremely rare in patients with focal lesions in the parenchyma.[3],[4] In our case, the patient thought that the MH were pseudohallucinations that he had been having.

With respect to the complex visual hallucinations, they mainly originate in the temporal lobe, likely involving the anteromedial limbic structures, although the posterior parietal lobe has been implicated as well.[7] In the literature, a patient who presented with nonlesional focal seizures of temporal lobe origin has been reported to be having a similar type of seizures. He presented with cinematographic visual hallucinations consisting of seeing people in colour but with interruptions, as if embedded in frames, as may be visualised while seeing an old movie.[8] Similar to this reported case, our patient had complex visual hallucinations, which manifested to him as if he was watching a videoclip, with a simultaneous musical auditory component. Complex visual hallucinations may also have an auditory component. This is often underdiagnosed because the patient does not report it perhaps due to the fear of being labelled as having a psychiatric illness.

Concerning the etiology, MRI demonstrated a granular-nodular lesion in the left superior temporal gyrus, located in the primary auditory cortex (Heschl's area), which explains the auditory clinical manifestations. According to the Carpio's and Del Brutto's criteria, the lesion was highly suggestive of NCC as the patient lived in an endemic zone, there was an observed involution of the lesion with cysticidal drug, and the MRI showed the neurological image of a nodular enhancing lesion.[5],[6]

Mexico is an endemic area for NCC, where the calcified phase has been found in 10–20% of the general population. The granular-nodular phase in NCC has the potential to cause seizures. The presence of oedema around the lesion is thought to be due to the release of antigen from dead parasites. In our case, the presence of oedema around the lesion prompted us to treat him with corticosteroids in addition to anticonvulsants, a practice that is unproven but is widely accepted.[9],[10]

We observed an improvement in the patient's clinical symptoms with the initial treatment, and a deterioration in his status following the discontinuation of corticosteroids; therefore, we decided to continue this combination of anticonvulsants and steroids in the minimum effective dose to avoid a recurrence of the seizures. No neurosurgical intervention was mandated in our patient due to the low seizure frequency and the minimal impact of the seizures on his quality of life.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest

 
  References Top

1.
Dinges M, Riemer T, Schubert T, Prüss H. Musical hallucinations after pontine ischemia: The auditory Charles Bonnet syndrome? J Neurol 2013;260:2678-80.  Back to cited text no. 1
    
2.
Kumar S, Sedley W, Barnes GR, Teki S, Friston KJ, Griffiths TD. A brain basis for musical hallucinations. Cortex 2014;52:86-97.  Back to cited text no. 2
    
3.
Jacob P. Brunner, BS and Ronald G. Amedee, MD. Musical hallucinations in a patient with a presbycusis: A case report. Ochsner J 2015;15:89-91.  Back to cited text no. 3
    
4.
Woo PY, Leung LN, Cheng ST, Chan KY. Monoaural musical hallucinations caused by a thalamocortical auditory radiation infarct: A case report. J Med Case Rep 2014;8:400.  Back to cited text no. 4
    
5.
Carpio A, Fleury A, Romo ML, Abraham R, Fandiño J, Durán JC, et al. New diagnostic criteria for neurocysticercosis: Reliability and validity. Ann Neurol 2016;80:434-42.  Back to cited text no. 5
    
6.
Brutto OHD, Rajshekhar V, White AC, Tsang VCW, Nash TE, Takayanagui OM, et al. Proposed diagnostic criteria for neurocysticercosis. Neurology 2001;57:177-83.  Back to cited text no. 6
    
7.
Winton-Brown TT, Ting A, Mocellin R, Velakoulis D, Gaillard F. Distinguishing neuroimaging features in patients presenting with visual hallucinations. Am J Neuroradiol 2016;37:774-81.  Back to cited text no. 7
    
8.
Nelson AE, Gilliam F, Acharya J, Miranda S. A unique patient with epilepsy with cinematographic visual hallucinations. Epilepsy Behav Case Rep 2016;5:78-9.  Back to cited text no. 8
    
9.
Nash TE, Bartelt LA, Korpe PS, Lopes B, Houpt ER. Calcified neurocysticercus, perilesional edema, and histologic inflammation. Am J Trop Med Hygiene 2014;90:318-21.  Back to cited text no. 9
    
10.
Singh NN, Verma R, Pankaj BK, Misra S. Neurocysticercosis presenting as Weber's syndrome: A short report. Neurol India 2003;51:551-2.  Back to cited text no. 10
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