Opioid-induced toxic leukoencephalopathy: A case report and review of the literature

Abstract

ImportanceReports of toxic leukoencephalopathy (TLE) due to opioids have been extensively documented within the adult literature. There is a paucity of literature with respect to the incidence, complications, and outcomes of TLE in the pediatric population.ObjectiveTo describe a rare complication of opioid ingestion in the pediatric population and serve as the first large review of published cases of opioid-induced leukoencephalopathy. Thirteen case reports with varying treatments are herein reviewed in addition to our own case. The range of treatment modalities, morbidity and mortality are broad and outcomes secondary to supportive care versus neurosurgical intervention is explored.Evidence reviewAll cases of pediatric opioid-induced toxic leukoencephalopathy published on pubmed and google scholar were included in this review.FindingsWe report the case of a 4-year old male surgically treated for acute oxycodone-induced TLE who initially presented with Glascow Coma Scale of 4 and a comatose state for weeks. Over the next several months he recovered with spasticity of all extremities, oral aversion, substantial vision loss, and the ability to speak in short sentences. In addition, we found thirteen other reported cases of opioid-induced leukoencephalopathy reported in the literature. The treatment approaches described range from supportive care alone, to invasive neurosurgical interventions including placement of extraventricular drains, removal of hemorrhagic tissue, and craniectomy. The outcomes of patients with opioid-induced leukoencephalopathy is also variable. Reports demonstrate a range of outcomes that include patients who died to those with no residual neurologic deficits.ConclusionsThis review of reported pediatric cases of opioid-induced leukoencephalopathy highlights the importance of early neurosurgical intervention for prevention of devastating outcomes.

Posterior Reversible Encephalopathy Syndrome (PRES) in a Patient with Opioid Use Disorder

“…There have been several case reports about Posterior Reversible Encephalopathy Syndrome (PRES), also known as Toxic Leukoencephalopathy resulting from methadone toxicity and/or heroin overdose [8,14,17]. Heroin has lipophilic properties and acetylation of its hydroxyl groups increases its blood-brain barrier penetration by 100-fold [11].…”

“…Pglycoprotein inhibition at the blood-brain barrier acutely disrupts the blood-brain barrier permeability and selectivity in the nucleus accumbens [11,12]. Cases of toxic leukoencephalopathy have been reported in patients with illicit heroin vapor inhalation [13][14][15][16]. However, literature about heroin use and PRES is scarce.…”

Lesson of the month: Oxycodone-induced leukoencephalopathy: a rare diagnosis

“…Toxins that disrupt myelin sheath and/or axons include drugs of abuse (heroin and opioids); environmental factors (carbon monoxide), occupational factors (paint) or therapeutics (anti-neoplastic, antimicrobial and immunosuppressives). 2,3 Interhemispheric and intrahemispheric pathways that serve cognition and emotion (neurobehaviour) are predominantly involved. Hence the most important clinical feature includes a change in mental status.…”

“…There are further reports of, predominantly, children presenting unconscious or unresponsive with WM changes in the cerebrum or cerebellum after inadvertent exposure to heroin, morphine or methadone. 2 One Belgian case report was on a 65-year-old woman who had extensive, symmetrical cerebral WM changes after inadvertently ingesting a high dose of methadone. 5 Oxycodone-associated neurotoxicity was first published in 2010.…”

“…To the authors' knowledge, there are nine such cases reported in the literature (summarised in Table 1). 2,[6][7][8][9][10][11] These patients presented with varying symptoms. With opiate prescriptions on the rise, it is imperative to be aware of this clinical condition.…”