Goldner Journal of Medical Case Reports 2012, 6:65

http://www.jmedicalcasereports.com/content/6/1/65 JOURNAL OF MEDICAL

CASE REPORTS

CASE REPORT Open Access

Metoprolol-induced visual hallucinations:

a case series
Jonathan A Goldner1,2

Abstract
Introduction: Metoprolol is a widely used beta-adrenergic blocker that is commonly prescribed for a variety of
cardiovascular syndromes and conditions. While central nervous system adverse effects have been well-described
with most beta-blockers (especially lipophilic agents such as propranolol), visual hallucinations have been only
rarely described with metoprolol.
Case presentations: Case 1 was an 84-year-old Caucasian woman with a history of hypertension and
osteoarthritis, who suffered from visual hallucinations which she described as people in her bedroom at night.
They would be standing in front of the bed or sitting on chairs watching her when she slept. Numerous
medications were stopped before her physician realized the metoprolol was the causative agent. The hallucinations
resolved only after discontinuation of this medication.
Case 2 was a 62-year-old Caucasian man with an inferior wall myocardial infarction complicated by cardiac arrest,
who was successfully resuscitated and discharged from the hospital on metoprolol. About 18 months after
discharge, he related to his physician that he had been seeing dead people at night. He related his belief that
since he ‘had died and was brought back to life’, he was now seeing people from the after-life. Upon
discontinuation of the metoprolol the visual disturbances resolved within several days.
Case 3 was a 68 year-old Caucasian woman with a history of severe hypertension and depression, who reported
visual hallucinations at night for years while taking metoprolol. These included awakening during the night with
people in her bedroom and seeing objects in her room turn into animals. After a new physician switched her from
metoprolol to atenolol, the visual hallucinations ceased within four days.
Conclusion: We suspect that metoprolol-induced visual hallucinations may be under-recognized and under-
reported. Patients may frequently fail to acknowledge this adverse effect believing that they are just dreaming, or
may be embarrassed to report visions that they feel will not be perceived by others to be real. Similarly, healthcare
providers can also fail to recognize this visual toxicity or attribute visual hallucinations to concurrent illness or other
medications. Clinicians must maintain diligent surveillance when managing patients receiving this drug.

Introduction the literature on this topic and hypothesize why this

The central nervous system (CNS) adverse effects of neurologic toxicity may be under-recognized and under-
beta-adrenergic blockers, including visual hallucinations, reported.
have been largely associated with highly lipophilic agents
such as propranolol, timolol and pindolol [1,2]. Meto- Case presentations
prolol is one of the most commonly prescribed beta- Case 1
adrenergic blocking agents but visual hallucinations An 84-year-old Caucasian woman with a history of
associated with its use have been reported only rarely hypertension and osteoarthritis suffered from visual hal-
[3-5]. Here, the cases of three patients with visual hallu- lucinations for several years. She would awake at night
cinations induced by metoprolol are reported; we review to see people standing at the foot of her bed or sitting
on a chair in her room watching her sleep. These people
Correspondence: jgoldner@pmchealthsystem.org would not converse with her but were frightening. She
1
Department of Medicine, Pocono Medical Center, East Stroudsburg, PA, USA had no history of neurological or psychiatric illness nor
Full list of author information is available at the end of the article

© 2012 Goldner; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
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were there any significant neuropsychiatric findings on Case 3

physical examination. Her medications consisted of A 68-year-old Caucasian woman who suffered from
aspirin, a calcium channel blocker, an angiotensin con- severe hypertension, hypothyroidism and depression,
verting enzyme inhibitor and metoprolol tartrate 50 mg reported visual hallucinations at night for two years while
orally twice a day for blood pressure control. She used taking metoprolol succinate 100 mg orally once a day.
acetaminophen for control of her arthritis symptoms. These included awakening during the night with people
She did not have any hallucinations any other time of in her bedroom and seeing objects in her room that
day or night. A neurological work up included a mag- turned into animals. Her other medications included
netic resonance imaging of her brain, an electroencepha- amlodipine, enalapril, escitalopram, levothyroxine and
lography and neurocognitive testing, which was aspirin. When questioned, she believed the hallucinations
unrevealing. A full complement of laboratory tests started about the same time that she was placed on meto-
showed normal thyroid functions, vitamin B12 and prolol for her hypertension. Her physical examination
folate levels. She had no history of alcohol or drug use. and laboratory evaluation were unrevealing. She had no
She was unsure how long she had been on all of her history of alcohol or illicit drug use. She described the
medications but knew that she had been taking meto- visual disturbances to her previous family physician, who
prolol for at least two years. All of her antihypertensive felt this was likely related to her medical problems
medications were discontinued besides the beta adrener- including her depression. Her neurologic and psychiatric
gic blocker before her physician realized the causative examinations were otherwise unremarkable except for a
agent was metoprolol. Her visual hallucinations stopped flat affect. She subsequently visited a new physician who
completely within several days of ceasing this switched her from metoprolol to atenolol, with resolution
medication. of her night-time visual hallucinations within four days.

Case 2 Discussion
A 62-year-old Caucasian man had an inferior wall myo- For decades, beta-adrenergic blocking agents have been
cardial infarction that was complicated by cardiac arrest known to cause adverse CNS effects including psychiatric
shortly after arrival to the emergency department. He syndromes, bizarre and vivid dreams, sleep disturbances,
was successfully resuscitated after approximately one to delirium, psychosis and visual hallucinations [6,7]. The
two minutes of ventricular fibrillation with electrical medical and pharmacologic literature clearly describe the
defibrillation. He otherwise had an uneventful recovery highly lipophilic agents, such as propranolol, as most fre-
and was discharged from the hospital on aspirin, isosor- quently displaying neurologic toxicities [1,8,9]. In 1978,
bide, lisinopril and metoprolol tartrate 100 mg orally Fleminger reported an incidence of 14.3% to 17.5% of
twice a day. He had no history of neurologic or psychia- visual hallucinations and illusions with propranolol
tric abnormalities or significant findings in this regard among patients attending a hypertension clinic [8].
on physical examination. He used alcohol rarely but Metoprolol is a popular cardiovascular drug whose
there was no illicit drug use. widespread use can be attributed to its generic and
About 18 months after discharge, our patient asked to affordable short- and long-acting formulations, and its
speak to his physician in a confidential manner. He asked established safety and efficacy in treating a variety of
that his wife not be told, and subsequently related that he cardiovascular disorders such as hypertension, arrhyth-
had been seeing dead people at night. He would awake mias, angina pectoris, acute coronary syndromes and
and see faceless figures sitting at the side of his bed; the congestive heart failure. There is a paucity of data on
figures would vanish as he became totally awake. He the occurrence of CNS side effects with the administra-
believed that since he ‘had died and was brought back to tion of metoprolol. Metoprolol, which has an intermedi-
life’ during the acute phase of his myocardial infarction, ate degree of lipophilicity (a property known to enhance
he was now seeing people from the after-life. He would CNS drug penetration, as opposed to hydrophilicity,
also see animals at times. The visual hallucinations which limits brain entry), has rarely been reported to
started immediately after he was discharged from the cause visual hallucinations despite its common usage
hospital at which time he had been placed on metoprolol. [3-5]. In light of our experience, we suspect that the
Upon discontinuation of the metoprolol the visual distur- occurrence of visual hallucinations with this drug may
bances resolved within several days. Our patient asked to occur more frequently than previously reported.
be restarted on metoprolol after considering the benefi- Under-reporting and under-recognition of hallucinations
cial aspects of the drug on his heart disease. He now caused by metoprolol might be due to several factors.
understood that the visual hallucinations were related to First, patients may not complain of visual disturbances
the medication, and they were no longer frightening to because they fail to connect the symptoms with the drug,
him when they subsequently occurred. as in our second case. Some patients may attribute beta-
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blocker-associated hallucinations to dreaming or night- Conclusions

mares [8]. As Fleminger reported with propranolol, all Metoprolol, a widely used beta-blocker, has been asso-
three of our patients had their visual hallucinations while ciated with visual hallucinations and CNS disturbances.
awakening from sleep in the hypnopompic state [8]. Multiple reasons may lead to under-recognition and
Furthermore, patients may be too embarrassed to discuss under-reporting of this adverse drug effect, by both
illusions that they fear may be confused by others as being patients and physicians alike. The true incidence of
a result of mental illness or excessive drug or alcohol use. visual hallucinations related to metoprolol is unknown.
Finally, physicians may also fail to recognize this adverse Clinicians are urged to maintain diligent surveillance
drug effect and may consider the visual disturbance to be when managing patients receiving this drug.
related to existing medical or psychiatric conditions, as in
our first and third case. Consent
Sirois reported that hallucinations associated with Written informed consents were obtained from the
metoprolol may remain an isolated symptom, or they patient or next of kin for publication of this case series.
may evolve into delirium in older patients with cognitive Copies of the written consents are available for review
deficits [5]. For both of the patients he described, visual by the Editor-in-Chief of this journal.
hallucinations began within 24 hours of the initiation of
metoprolol and the side effect was discovered shortly
Acknowledgements
thereafter during their hospitalization. This is unlike our The author wishes to thank Raymond Smego Jr., MD, Associate Dean for
patients, who did not recognize the adverse reaction Educational Development at The Commonwealth Medical College, for his
themselves or have it recognized by their physician for a review and critique of this manuscript.
long period of time. The delay in diagnosing the cause Author details
of the hallucinations in our patients was either related 1
Department of Medicine, Pocono Medical Center, East Stroudsburg, PA,
to the patient’s reluctance to inform anyone of the visual USA. 2Commonwealth Medical College, Scranton, PA, USA.
disturbances, the patient’s family associating the halluci- Competing interests
nations with other medical or psychiatric disorders they The author declares that they have no competing interests.
thought the patient had or the physician’s inability to
Received: 6 September 2011 Accepted: 15 February 2012
recognize the medication as the etiology for the disor- Published: 15 February 2012
der. Our patients had no visual disturbances during
other times nor a psychiatric or medical reason that References
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Cite this article as: Goldner: Metoprolol-induced visual hallucinations:
beta-blocker penetration of the blood-brain barrier or a case series. Journal of Medical Case Reports 2012 6:65.
the occurrence of CNS side effects [10-12]. These third
generation beta-blockers may be a good alternative to
metoprolol if visual hallucinations occur.