Severe cerebellitis following methadone poisoning

Abstract

We report a 3-year-old girl with an unusual presentation of cerebellitis following ingestion of methadone. CT showed diffuse symmetrical swelling and oedema of the cerebellum resulting in compression of the fourth ventricle and hydrocephalus. The changes were confirmed on MRI with the addition of watershed injuries. These findings represent a toxic encephalopathy and have been reported in previous cases of heroin intoxication by inhalation, but rarely following opioid ingestion. The aetiology of the watershed infarcts is discussed.

Methadone-Induced Toxic Leukoencephalopathy: MR Imaging and MR Proton Spectroscopy Findings

“…[2][3][4][5][6][7] There are only a few reported cases of severe methadone-induced toxic leukoencephalopathy that include imaging findings. [8][9][10] The imaging findings in our patient are similar, though not identical, to previously reported MR imaging and spectroscopic white matter changes observed in heroin-vapor-inhalation toxicity (a practice known as "chasing the dragon"). [2][3][4]6,7 In general, the different case reports mention similar symmetric and confluent high-signal-intensity changes in the cerebral white matter observed on T2-weighted and FLAIR images with, as also observed in our patient, sparing of the subcortical U-fibers.…”

“…Furthermore, the few case reports with CT and MR imaging findings describing brain damage after a methadone overdose all reported cerebellar swelling with subsequent de-velopment of acute hydrocephalus. [8][9][10] In these reports, all the patients were children with a maximum age of 3 years. However, to the best of our knowledge, this is the first case report of methadone intoxication in an adult.…”

Possible mechanisms of rapid neurological deterioration and acute hydrocephalus in drug abusers

“…Sir, I read with interest the article by Mills et al [1] describing opioid poisoning as a cause of severe cerebellitis in a child. We have observed a similar presentation in at least four individual patients suffering profound heroin addiction.…”

“…This presentation is now becoming a nearly constant feature for intravenous drug abusers presenting with a sudden decreased level of consciousness, although in many of them except the above four, other causes of coma have been ruled in [1,2]. A few theories may explain this picture in such patients.…”

“…Following opioid intoxication, respiratory compromise ensues, causing anoxic encephalopathy and diffuse oedematous swelling of the brain. A form of toxic leukoencephalopathy causing cerebellar oedema and hydrocephalus has also been described resulting from inhalation of heroin, and also from methadone poisoning [1,3]. In a case report by Derlon et al [4], traumatic compression and occlusion of the left vertebral artery at the level of C2 during an alcoholic coma caused oedematous cerebellar infarction and hydrocephalus.…”