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Musical Hallucinations After Living-Donor Liver Transplantation

Key Words: Letters to the Editor • Transplantation • Hallucinations

TO THE EDITOR: Almost all liver transplants in Japan are from living donors. Ninety percent of the recipients are children with liver failure. There is little chance for adult patients to receive a transplant. Recently, there has been a gradual trend for adult patients to receive partial-liver transplants from their own children, although the total number is still small. We report a patient with musical hallucinations after a successful partial-liver transplantation from a living donor.

Case Report

A 54-year-old woman received a living-donor partial-liver transplant from her son. She had suffered from familial amyloid polyneuropathy (FAP) for 2 years. Her complaints were hypogeusia, dysuria, and gait disturbance. Thereafter, she exhibited congestive heart failure, with pleural effusion and systemic edema. Amyloid deposition was noted on cardiac scintigram. Genetic analysis revealed a transthyretin mutation. Circulating transthyretin is derived from the liver, and liver transplantation is performed for variant transthyretin-associated FAP.¹

The patient has one son (age 36) who offered to be a liver donor to save his mother's life. Although the mother hesitated to receive a partial liver from her son, he expressed a strong desire to become her donor. She was obliged to accept the transplant because of the life-threatening amyloidosis. Before surgery, the patient was found to harbor strong guilt feelings over the receipt of a portion of her son's liver, but the relationship between the mother and son was positive and strong. No psychiatric symptoms were observed in either donor or recipient.

The medical course posttransplantation was unremarkable. On the fifth day postoperatively, the recipient complained of suicidal ideation associated with guilt feelings for her son. Three days later, these complaints disappeared. One month after the transplant, musical hallucinations appeared. The hallucinations lasted 3 weeks and were unaffected by day or night. She heard Enka (traditional Japanese ballads) for several hours daily, two or three times a day. She felt comforted because she enjoys Enka very much. She was reluctant to undergo psychiatric treatment for the hallucinations.

Since the transthyretin mutation was not present in the donor liver, transplantation prevented further amyloid deposition. However, the accumulated cardiac and systemic amyloidosis from prior to the transplant remained, and the patient's symptoms of congestive heart failure and neuropathy continued despite the successful liver transplant. A sibling suffering from the same FAP had died of heart failure. Information on the sibling's death and the prognosis of systemic amyloidosis caused considerable anxiety. The patient was reporting musical hallucinations, including Enka and Okyo (Buddhist hymns), which would appear alternatively for 4 to 5 hours a day. She revealed that she feared for her own death but admitted that the musical hallucinations comforted her, and she experienced the music, in particular the Enka, with great relief. Haloperidol (1.5 mg/day orally) was prescribed, but the musical hallucinations did not disappear. As her anxiety and fear of death decreased with counseling, the comforting musical hallucinations gradually disappeared.

Discussion

Recent studies have described "paradoxical psychiatric symptoms," which can occur after successful transplantation in the absence of tissue rejection or other medical complications. The hallucinations sometimes appear after living-donor transplantation and may be expressed by various forms of depression or psychological pain.^2,3 Moreover, living-donor recipients have strong feelings of guilt toward their donors but cannot verbalize their inner feelings.^2,3 In this case, the recipient's son offered his own liver to save his mother's life. Although the recipient had strong guilt feelings, the recipient suppressed these guilt feelings and conflicts. Indeed, the clinical course was positive after transplant, and the suppressed feelings manifested as musical hallucinations. Guilt and anxiety over death appear to be closely associated with the manifestation of musical hallucinations.

Musical hallucinations, such as the hearing of melodies, are rare.^4,5 These hallucinations may occur in various diseases.^4,5 In this case, the experience of the musical hallucinations was comforting to the recipient, suggesting that they may have played a role as a psychological defense for her strong guilt feelings toward the donor and anxiety and fear over death. In Japan, parent-recipient to child living-donor transplantation has sometimes been performed as a lifesaving measure in adult patients with liver failure. This case suggests that consultation-liaison psychiatrists should carefully evaluate the psychological condition of recipients and donors before transplantation, with particular attention to nonverbalized feelings of anxiety and conflict.

REFERENCES

1. Stangou AJ, Hawkins PN, Heaton ND, et al: Progressive cardiac amyloidosis following liver transplantation for familial amyloid polyneuropathy. Transplantation 1998; 66:229–233[Medline]
2. Fukunishi I: Japanese consultation-liaison psychiatry in the areas of organ transplantation and cancer care. Psychiatric Times 1998, Vol XV, pp 48–49
3. Fukunishi I, Ohara T, Kobayashi M, et al: "Paradoxical depression" in a female donor after living kidney transplantation. Psychosomatics 1998; 39:396–397[Free Full Text]
4. Berrios GE: Musical hallucinations: a historical and clinical study. Br J Psychiatry 1990; 156:188–194[Abstract/Free Full Text]
5. Berrios GE: Musical hallucinations: a statistical analysis of 46 cases. Psychopathology 1991; 24:356–360[Medline]

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Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via HighWire Citing Articles via Google Scholar Articles by Fukunishi, I[e. Articles by Makuuchi, M. Search for Related Content PubMed Citation Articles by Fukunishi, I[e. Articles by Makuuchi, M. General Topics in Psychiatry Syndromes Secondary to General Medical Disorders

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