Visual Hallucinations and Altered Mental Status Exacerbation Associated with Acute Levodopa Withdrawal

Abstract: A 70s-aged female Parkinson’s Disease patient was admitted for encephalopathy, affective changes, and hallucinations. She was anxious, but intermittently alert and oriented. She stopped taking her carbidopa-levodopa 25-100 mg, three tablets, thrice daily, one week prior due to abdominal pain. She subsequently experienced weakness, tremors, and hallucinations of people around her stove, then called 911. Her son verified her recent medication non-adherence. She lived alone and was unsupported over recent holidays. The possibility of accidentally taking excess levodopa was firmly denied. The patient started levodopa five years ago, periodically complaining of stomach pain. Geriatric psychiatry outpatient managed her controlled depression. She previously had mild shadow hallucinations and cognitive decline, but the current episode was markedly worse. During inpatient neurology, confusion and agitation worsened. Infectious workup and head CT were unremarkable. Levodopa-carbidopa was restarted; quetiapine, pimavanserin, and rivastigmine were added. Psychiatry adjusted home lorazepam, continuing mirtazapine and desvenlafaxine. Her mental status overall improved to an outpatient-manageable state over six weeks. Common high-dose dopaminergic agent effects include psychosis and hallucinations. Sharp medication tapers also cause problems: E.g., Dopamine Agonist Withdrawal Syndrome with medications like pramipexole involves dysphoria and panic attacks. Exacerbated altered mental state and hallucinations from levodopa withdrawal is more unique; it has been observed, but mainly in rare older case studies. More common levodopa withdrawal complications include stiffness, rigidity, tremor, and thrombosis risk, versus hallucinations. Moreover, visual hallucinations, in general, have an inconsistent literature association with dopaminergic agents. Therefore, this case presents an unusual levodopa withdrawal manifestation for clinical consideration.Short Description: Parkinson’s Disease and its treatments have been associated with affective changes, psychosis, and sensorial abnormalities given this pathology’s roots in dopaminergic neural circuitry. Traditionally, this occurs with medication overuse or dopamine agonist withdrawal. We present a unique case of visual hallucinations and altered mental status exacerbation in response to an unplanned levodopa withdrawal. This has rarely been observed before, but largely in older reports. Our case showcases another psychiatric manifestation of acute dopaminergic medication changes.Name of Sponsoring Organization(s): N/A