When worlds collide: Vivid visual hallucinations, cerebral granulomas, and familial risk – A case study and discussion

Visual hallucinations (VH) pose a diagnostic challenge due to their occurrence in both psychiatric and neurological disorders. Although often linked to psychotic conditions such as schizophrenia, VH can also stem from organic brain abnormalities. We describe the case of a 41-year-old woman experiencing vivid, interactive VH of a childlike figure for 1 year, later accompanied by paranoid beliefs and sleep issues. Her elder sister has a confirmed schizophrenia diagnosis. Brain imaging revealed multiple calcified granulomas across various regions and widespread cerebral and cerebellar atrophy. Initial treatment with trifluoperazine led to extrapyramidal side effects, prompting a switch to clozapine with a cross-tapering approach. This case underscores the complex interplay of organic brain pathology, genetic predisposition, and treatment-related challenges in the context of VH and psychosis. We explore diagnostic considerations, the role of neuroimaging findings, and the effective management strategy, highlighting the importance of a thorough neuropsychiatric evaluation and individualized treatment.