To present a case of peduncular hallucinosis in the setting of macular degeneration, and compare and contrast the presentation of peduncular hallucinosis with that of Charles Bonnet syndrome.

Peduncular hallucinosis (PH) is characterized by vivid visual hallucinations occurring in fully lucid patients.¹ Injury to the basal ganglia, thalamus, midbrain, and pons have been implicated.^1,2 It is most often reported as a presenting symptom of various tumors, following stroke, and as a complication of neurosurgery.² Leading hypotheses involve the ARAS.³ On the differential is Charles Bonnet syndrome, which occurs due to reduced visual input secondary to ophthalmologic or vascular disease.⁴

76-year-old male with a past medical history of diabetes, hypertension, hyperlipidemia, and macular degeneration presented to the ED with hallucinations for one day. He fell one day prior to onset, but did not hit his head or lose consciousness. Immediately following the fall, he noticed human-like figures occupying his room. CT of the head was interpreted as negative and the patient was discharged. He returned three days later after no improvement. ROS, drug history, and family history were unremarkable. He could visualize, communicate with, and feel the touch of human-like figures, fully aware that these hallucinations were not real. Full neurological exam, including mental status, was unremarkable with the exception of visual fields and acuity. MRI of the head and neck confirmed a left pontine lacunar infarct and a diagnosis of PH was made. Aspirin and statin were initiated for secondary prevention of stroke and an echocardiogram was ordered. Two days later, the patient denied hallucinations. Ways to alleviate hallucinations and outpatient pharmaceutical intervention were discussed should symptoms return. 

PH is a rare cause of hallucinations, and work-up should be considered in any individual experiencing hallucinations with an otherwise unremarkable mental status exam.