Heroin-induced toxic leukoencephalopathy – “chasing the dragon” in South Africa

Abstract

Purpose In South Africa, many illicit drugs have only recently been introduced and drug-related complications are often new to treating physicians. Heroin-induced leukoencephalopathy has been reported elsewhere in patients who inhale heated heroin vapors, a method known as “chasing the dragon.” The purpose of this paper is to present two patients, known to have inhaled heroin a few weeks prior to presenting with progressive neurological deficits. Design/methodology/approach Case presentations: two young males presented independently within eight weeks of one another with progressive slurring of speech, incoordination and weakness of the limbs over a period of two to three weeks. Both were known heroin addicts, and were known to one another, and both had inhaled heroin prior to the onset of symptoms. Findings The patients presented with a pancerebellar syndrome with marked bilateral upper motor neuron signs. CT scans showed diffuse symmetrical hypodense lesions involving the cerebral and cerebellar white matter with normal CSF. Both patients deteriorated neurologically, became cardiovascularly unstable and demised. Postmortem in one of the patients showed a prominent spongiform leukoencephalopathy consistent with reports of heroin-inhalation injury to the brain. Research limitations/implications Toxic leukoencephalopathy due to heroin vapor inhalation was first described in the Netherlands in 1982. It has not been reported to occur with other modes of heroin use; an unknown toxin contained in heroin pyrolysate which forms when heroin is heated, may be causative. Brain MRI typically shows diffuse, symmetrical white matter hyperintensities on T2 and fluid-attenuated inversion recovery sequences in the cerebellum, posterior cerebrum and posterior limbs of the internal capsule with a posterior-anterior gradient. Pathologically, spongiform degeneration with relative sparing of subcortical U-fibers is seen. No treatment has been proven effective, but antioxidants and Vitamin E may be beneficial. Mortality is high at 23-48 percent. Practical implications This report emphasizes that spongiform leukoencephalopathy as a rare consequence of inhaling heroin vapors does occur in South Africa and clinicians should consider this disorder in their differential diagnosis of acutely developing leukoencephalopathy. Social implications An awareness program regarding this grave condition is planned. Originality/value The cardiovascular complications of patients inhaling heroin vapor has not been highlighted previously. These are the first patients from Africa described with this condition. A toxic component appears likely.

Chasing The Dragon

“…This continues to be a problem, not only locally but abroad. 8 Although the mechanism of neurologic injury is unknown, it has been hypothesized that unidentified substances in the heroin pyrolysate (the product of chemical change caused by heating) may be responsible.…”