(100) Steroid-Induced Musical Hallucinosis

Significance: Musical hallucinations (MH) are music perceived in the absence of an external sound and are related to neurologic, psychiatric, and pharmacologic etiologies. We report a unique MH case in a 59-year-old male post methylprednisolone treatment.



Case: A 59-year-old Spanish-speaking male with interstitial pulmonary fibrosis, lung transplant, and no psychiatric history was admitted for nausea/vomiting, hyponatremia, and pulmonary function decline due to acute cellular rejection. For this, he was prescribed methylprednisolone 500mg daily for 3 days.

Within hours of his initial steroid administration, he reported auditory hallucinations of a Mexican song, "Mi Morena." They were continuous, right-sided, and experienced as hearing the singer’s voice and band instruments played through a speaker. Reality testing remained intact with non-contributory psychiatric or neurologic ROS and MSE. There was no evidence of delirium and a neurologic evaluation was without focality. A CTH and interval metabolic panels were unremarkable, showing hyponatremia resolution prior to hallucination onset. Within 24 hours of methylprednisolone cessation, the MH intensity decreased to intermittent with silence between multi hour episodes and within 48 hours, they ceased without recurrence. Given the time limited methylprednisolone course and minimal patient distress, antipsychotic treatment was deferred and the anti-rejection regimen was not altered.



Discussion: MH manifest as the perception of songs or musical elements in the absence of auditory input1. They are categorized as idiopathic or secondary with heterogeneous etiologies, including neurological (stroke, epilepsy), psychiatric (psychosis, OCD, substance use) and pharmacologic precipitants (intoxication, withdrawal)2. Literature discussing pharmacologic precipitants to MH is sparse, with case reports implicating ototoxic agents (salicylates, quinine, cisplatin), antidepressants (clomipramine, imipramine), antiepileptics (phenytoin, carbamazepine), antihypertensives/antiarrhythmics (propranolol, amiodarone), and neurotransmitter modulators (benzodiazepines, amphetamines, ethanol)3.

The mechanism of steroid-induced MH is unknown. Current hypotheses involve hypoacusis or reduced hearing sensitivity. Hypoacusis, whether age related or due to auditory circuit disruption (i.e. ototoxicity), results in sensory deprivation-induced disinhibition of auditory cortices, leading to overactivity of the auditory cortex and related hallucinations4. The phenomenon, coined Oliver Sacks’ syndrome, is akin to phantom limb sensations in amputees or the visual release phenomenon described in Charles Bonnet syndrome. Dopamine and serotonin signal alteration, similar to steroid-induced psychosis and mania, may increase risk of MH development.

MH treatment options are as diverse as etiologic sources. Hearing aids are indicated in patients where hypoacusis is present and serve to reduce auditory cortex overactivity by reducing sensory deprivation4. In cases of MH due to ototoxic agents, symptom reversibility depends on damage extent and exposure duration, though MH appear largely self-limited with agent cessation. Psychopharmacologic interventions have been studied including antidepressants, antiepileptics, acetylcholinesterase inhibitors, antipsychotics, and benzodiazepines, with emerging evidence for TMS5. Indication for use depends on etiology and comorbidities, though none are curative with a focus on reducing symptom severity and patient distress.



References:
1. Berrios GE. 10.1192/bjp.156.2.188
2. Evers S. 10. 1016/j.jns.2004.08.004
3. Al-Awad FA. 10.29333/ejgm/13522
4. Zein Met. 10.1016/j.psym.2020.06.009
5. Coebergh J. 10.3389/FPSYG.2015.00814

Presentation Eligibility: Not previously published or presented

Diversity, Equity, and Inclusion: The case illustrates how neuropsychiatric disorders can manifest through culturally relevant experiences, highlighting the importance of recognizing the influence of cultural context in disease presentation and diagnostics. The AH experienced by the patient (the Mexican song "Mi Morena") underscore the cultural dimension of hallucinations, reminding us of the importance to culturally competent healthcare.

In addition, the speaker panel represents diversity within medicine, including a low SES upbringing, Latino, LGBTQ, first generation physician trainee, an LGBTQ physician that was originally a social worker, and an Asian American.