Disclosures: Amara Nasir, MD: No financial relationships or conflicts of interest

Case Diagnosis: Charles Bonnet Syndrome (CBS).

Case Description: 65-year-old male with a past medical history of diabetes mellitus, hypertension, and a recent stroke three months ago with residual right-sided hemiplegia presented to the emergency department with right-sided pain and numbness. On examination, he had right-sided weakness and decreased sensation. No visual field defects were noted. CT scan showed a new left middle cerebral artery (MCA) infarct involving the left frontal and parietal lobes, left thalamocapsular region and left basal ganglia. EEG did not reveal any pathology. Work up revealed severe left carotid stenosis for which he underwent carotid endarterectomy. He was admitted to acute rehab for further rehabilitation. He reported seeing butterflies episodically, but at the same time he knew they were not real.

Setting: Inpatient stroke and rehab unit.Assessment/

Results: Psychosis, dementia, delirium, and visual deficits were ruled out. He was diagnosed with CBS. He received therapy which included reassurance, teaching how to block hallucinations, training for certain rapid eye movements/blinking to help suppress the hallucination in addition to the usual stroke rehabilitation therapy.

Discussion: CBS usually presents with simple and complex visual hallucinations (VHs). Simple VH include shapes and patterns, while complex include clear, life-like images or scenes. These occur due to damage along the visual pathway, commonly due to age-related macular degeneration, diabetic retinopathy, glaucoma and occipital lobe infarcts/seizures. Our patient did not have any of these common reasons for his complex VH: his symptoms were likely due to involvement of the vision-associated cortical areas or tracts passing through the parietal lobe and thalamus which may lead to VH.

Conclusion: Diagnosing CBS requires a multidisciplinary approach and is a diagnosis of exclusion. Since CBS is not commonly recognized by all clinicians, and patients may fear being diagnosed with a psychiatric disorder, it is underreported. Rehabilitation plays an important role in recovery.

Level of Evidence: Level V

« Back to AAPM&R Annual Assembly 2021

PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/i-see-butterflies-a-case-report-of-a-patient-with-charles-bonnet-syndrome/