Diffuse subcortical white matter injury and bilateral basal ganglia neuronal loss after acute opioid overdose

Abstract

Opiate intoxication has been associated with life-threatening effects of sympathetic suppression and respiratory depression, but current literature is limited in describing its neurotoxic effects on the central nervous system. Here, we present the case of an otherwise high-functioning adolescent male who was found unresponsive after ingestion of approximately 3–4 fake oxycodone 10–325 mg pills laced with fentanyl. Magnetic resonance imaging showed evidence of diffuse T2 hyperintensities in the corpus callosum and bilateral frontal, parietal, and cerebellum indicative of diffuse white matter injury. In addition, there were distinct areas of restricted diffusion in the bilateral basal ganglia concerning for oxidative stress-mediated neuronal loss. His neurological exam improved with supportive treatment over the course of his hospitalization. Although limited literature has shown leukoencephalopathy to be associated with opioid overdose, we present a case of additional involvement of subcortical gray matter.

Clinical and neuroradiographic features of fentanyl inhalation-induced leukoencephalopathy

“…There have been prior reports of fentanyl-induced TLE. One report describes TLE following an overdose of fentanyl-contaminated fake oxycodone,25 while other cases involved the use of a fentanyl patch 26–28. There are also cases noted after oral ingestion of patches, intravenous or unknown routes of ingestion 29–32.…”

Opioid-Induced Leukoencephalopathies: A Report of Two Cases

“…ATL can be related to various toxic etiologies other than OI and is characterized by an abrupt start, while neurological symptoms may vary, depending on the degree and extent of brain injury [2]. Brain MRI typically shows white matter (WM) abnormalities of the periventricular region and centrum semiovale, which are confluent and symmetric on T2 and fluid-attenuated inversion recovery (FLAIR) images and with restricted diffusion (RD) on diffusion-weighted imaging (DWI) [2][3][4]. Due to its extremely variable clinical presentation, as well as potentially reversible nature, ATL is considered underdiagnosed.…”