hallucinations , predominantly visual in nature , can occur in parkinson disease ( pd ) and are often related to the antiparkinsonian drugs .
visual hallucinations are a well - recognized problem . besides visual hallucinations , patients with pd uncommonly experience different forms of hallucinations , such as auditory hallucinations .
auditory hallucinations occur in 8% to 13% of patients with pd and are generally accompanied by visual hallucinations .
auditory musical hallucinations ( amhs ) are rare complex auditory hallucinations in pd that have been reported in only 8 patients .
four patients for whom detailed information is available have been documented , and 2 of these patients were deaf ( table 1 ) . in patients with amhs caused by conditions other than pd , amhs are characterized by repetitive and usually uncontrollable musical patterns , unrelated to external stimulation .
in december 2005 , a 72-year - old right - handed woman with no clinically significant history of disease , including epilepsy , migraines , or mental disease such as schizophrenia , noticed a tremor in her right hand . in december 2007 , she noted slowness of movement , difficulty in walking in narrow spaces , and the onset of left hand tremor in addition to right hand tremor and presented at our hospital .
she showed features of moderate parkinsonism , including masked face , retropulsion , bradykinesia , and right - side - dominant rigidity and resting tremor .
the scores on parts i , ii , iii , and iv of the unified parkinson disease rating scale ( updrs ) were 0 , 14 , 24 , and 0 , respectively .
the scores on the mini - mental status examination ( mmse ) and frontal assessment battery were normal ( 30/30 ) and decreased ( 16/18 ) , respectively .
she was given levodopa ( 250  mg / day ) and immediate - release pramipexole ( 1.5  mg / day ) , and the severity of these symptoms had decreased in may 2008 . in august 2008 , she showed wearing - off phenomenon and had freezing of gait .
subsequently , she was given entacapone ( 200  mg / day ) in june 2010 and zonisamide ( 25  mg / day ) in july 2011 .
the scores on the mmse and zung depression scale were 29 and 45 , respectively . in july 2012 , selegiline ( 5  mg / day ) was started since the severity of freezing gait had intensified , and the patient frequently fell .
she was then given stable doses of levodopa ( 500  mg / day ) , immediate - release pramipexole ( 1.5  mg / day , 3 times per day ) , entacapone ( 200  mg / day ) , zonisamide ( 25  mg / day ) , and selegiline ( 5  mg / day ) .
neuroleptic drugs were not used . in december 2012 , we switched from immediate- to once - daily extended - release pramipexole in stable dosage because off - periods had increased .
after that , she often had visual hallucinations such as animals or human hands and auditory hallucinations such as rustling sounds . in april 2013 ,
the amhs were a quiet piano or often songs on a loud radio or background music over other sounds .
amhs did not occur every day , but when they did the music persisted all day while the patient was awake .
the amhs were unrelated to visual hallucinations as well as other auditory hallucinations of children talking together .
the music was unpleasant , but not objectionable , threatening or ego - syntonic , and it did not interrupt her daily activities .
although the hallucinations persisted , she requested no further measures to suppress the hallucinations , such as the reducing the doses of anti - parkinsonian drugs or using neuroleptic agents , because the hallucinations were non - threatening and tolerable . in october 2013 ,
zonisamide was increased to 50  mg / day because off - periods had increased .
after receiving the patient 's informed consent , we switched back from extended- to immediate - release pramipexole in a stable dosage in january 2014 to determine whether extended - release pramipexole was causing the amhs .
when the patient visited to our hospital 5 day after switching back to immediate - release pramipexole , she reported that recognizable subjects such as animals or persons that she previously saw clearly as visual hallucinations had disappeared , whereas some unrecognizable shadows were often evident .
amhs sometimes occurred for several hours , particularly in the early morning or evening , and other auditory hallucinations became faded .
twelve days after retuning to immediate - release pramipexole , visual hallucinations rarely occurred , and amhs and other auditory hallucinations had disappeared .
among the 5 patients including ours for whom detailed information are available , amhs in pd were non - specific incomprehensible tunes or different familiar or popular songs such as folk or lyrical songs , which were unrelated to an external stimulus .
the inability of patients to interrupt amhs might have been uncomfortable , but was not threatening .
female sex , hearing impairment , advanced age , psychiatric conditions , cognitive disorders , alcoholism , obsessive  compulsive disorders , and neurological conditions ( eg , seizure disorders , stroke , tumors , central nervous systems infections , and brain lesions in the dorsal pons , temporal lobes , and frontal lobes ) were reported as risk factors for amhs .
our patient had none of these risk factors except for female sex and advanced age .
in the 5 patients including ours , neither cognitive decline nor depression was evident during amhs , and disease severity and off - periods were apparently unrelated to amhs .
the intervals between the time of altering treatment with anti - parkinsonian drugs and the onset of amhs were long in 2 previous patients , and the authors did not mention any relation between amhs and anti - parkinsonian drugs . in another patient ,
however , short - term amhs were elicited by amantadine . in our patient , although other preceding dopaminergic treatments such as levodopa , entacapone , and selegiline might have been prerequisite to the development of the hallucinations , the auditory and visual hallucinations occurred after immediate - release pramipexole was switched to extended - release pramipexole , and similar findings have not been reported previously .
several months after that , amhs began . in studies of patients with advanced or early pd , switching from immediate- to
extended - release pramipexole was safe , and the most frequently reported side effects were dyskinesia or somnolence . in healthy male volunteers , the pharmacokinetics and tolerability of a once - daily extended - release formulation of pramipexole were similar to those of an immediate - release formulation of pramipexole given 3 times daily .
however , 2 patients with pd in whom dopamine dysregulation syndrome developed after switching from immediate - release to extended - release pramipexole have been reported .
amhs in pd were non - threatening , and dopaminergic treatment may predispose patients to amhs or be a unique possible cause of amhs .
 abstractauditory musical hallucinations ( amhs ) are rare complex auditory hallucinations in parkinson 's disease ( pd ) that have been limited previously . 
 the characteristics of amhs in pd remain uncertain . 
 we describe a 72-year - old woman with pd who presented with amhs . 
 the amhs occurred after immediate - release pramipexole was switched to extended - release pramipexole . 
 the amhs were a quiet piano or often songs on a loud radio or background music over other sounds . 
 the music was unpleasant , but not objectionable , threatening , or ego - syntonic , and it did not interrupt her daily activities . 
 amhs in pd were non - threatening , and dopaminergic treatment may predispose patients to amhs or be a unique possible cause of amhs . the hallucinations can occur after immediate - release pramipexole was switched to extended - release pramipexole . 
INTRODUCTION
CASE REPORT
DISCUSSION