Closed-Eye Visual Hallucinations Preceding Severe Alcohol Withdrawal

Abstract

Few existing cases of closed-eye visual hallucinations have been reported. These rare perceptual disturbances are distinct from open-eye visual hallucinations, as observed in Charles Bonnet syndrome. This case report discusses a 35-year-old male who presented with closed-eye visual hallucinations 24 hours before severe alcohol withdrawal. On initial presentation, the patient denied auditory or visual hallucinations. The day before the onset of severe alcohol withdrawal, the patient reported vivid, colorful, and lifelike visual hallucinations with his eyes closed which disappeared with eyes open. The hallucinations consisted of cartoon characters such as Daffy Duck, a lifelike blond woman with curly hair, and a tree-covered landscape. The patient endorsed awareness that the hallucinations were not real. The next day, the patient became acutely delirious with rapid onset of agitation, space-time disorientation, open-eye visual hallucinations, and emotionally disturbing illusions. The patient was promptly transferred to the intensive care unit (ICU) to manage severe alcohol withdrawal, including administration of intravenous sedation. During follow-up evaluation, the patient retained a clear memory of the closed-eye hallucinations. However, he had no recollection of the ICU course. Several etiologies were considered, including alcohol withdrawal complicated by polysubstance withdrawal and acute hepatitis, which resolved following pharmacological treatment. To the best of our knowledge, this is the first case report of its kind. Additional research is required to elucidate the etiology, mechanism, and clinical implications of closed-eye visual hallucinations.

Mild encephalitis/encephalopathy with a reversible splenial lesion (MERS)

“… 22 Hyponatremia could have predisposed the patient to closed‐eye visual hallucinations, typically associated with alcohol withdrawal and general anesthesia. 23 , 24 , 25 The disruption of information transmission combined with a predisposition for hallucinations might have triggered vivid visual memories upon eye closure. Further research is required to understand these mechanisms and their clinical implications fully.…”

“…In this case, tonsillitis, a common infection leading to SIRS, 21 may have increased blood–brain barrier permeability, allowing inflammatory mediators into the CNS 22 . Hyponatremia could have predisposed the patient to closed‐eye visual hallucinations, typically associated with alcohol withdrawal and general anesthesia 23–25 . The disruption of information transmission combined with a predisposition for hallucinations might have triggered vivid visual memories upon eye closure.…”