Toxic leukoencephalopathy after intravenous heroin injection: a case with clinical and radiological reversibility

Abstract

A 32-year-old man with a history of heroin dependence was discovered unconscious in his home after heroin injection; brought to the hospital, he regained consciousness, but he developed a confusional state, which turned to stupor, and weakness of the upper and lower limbs on the right side. The neurological examination revealed an altered conscious level with difficult awakening. The patient maintained a decorticate posture at rest. Cranial nerves were intact. There was a right hemiparesis. Plantar responses were extensor on the right side and downgoing on the left.Brain MRI (Fig. 1a, b, c) revealed diffuse, symmetric areas of hyperintensity in the periventricular white matter and in the semiovale centers; the DWI sequence showed a restricted diffusion compatible with cytotoxic edema and axonal damage. These findings were suggestive of a toxic spongiform leukoencephalopathy [1].The patient had no exposure to other white matter toxins. Serology was negative for HBV, HCV, and HIV. CSF was unremarkable (glucose, proteins, cell counts) and negative for oligoclonal bands and JC virus.Stupor resolved in few weeks and motor signs improved, so the patient was discharged and he started a neurological and psychiatric rehabilitation program.

Toxic leukoencephalopathy due to inhalational heroin abuse

“…Serology is usually negative for HBV, HCV, and HIV. [ 5 ] HSLE should be considered a diagnosis of exclusion, and therefore, a broad differential must be considered before the diagnosis. Herpes encephalitis, anoxic brain injury, posterior reversible encephalopathy syndrome, Creutzfeldt–Jakob Disease, progressive multifocal leukoencephalopathy, and autoimmune disease are among the differentials that should be considered.…”

“…However, there have been cases where toxic leukoencephalopathy was associated with heroin injection and intranasal administration. [ 3 4 5 ] A recent survey conducted in 2015 shows that this mode of abuse is on rise with an increase to over 30% from 11.5%. [ 6 ]…”

Neuroprotection or Neurotoxicity of Illicit Drugs on Parkinson’s Disease

“…Heroin is usually injected or smoked. The inhalation of the vapor, resulting from heroin heated on aluminum foil (chasing the dragon) has been associated with spongiform encephalopathy [272][273][274][275][276][277][278][279][280] and Parkinsonism [47,48]. However, despite of a case report describing temporary Parkinsonism in a patient who inhaled heroin vapor, it was found a reversible deficiency of tetrahydrobiopterin underlying the altered dopamine metabolism [48].…”

Opioid overdose in a child: case report and discussion with emphasis on neurosurgical implications

“…2,27,34 The classic radiological hallmark of narcotic encephalopathy in children is symmetric white matter changes, best observed on T2-weighted MR images, in both the cerebrum and the cerebellum. Often, there is sparing of the anterior limb of the internal capsule and proximate subcortical and periventricular white matter.…”

“…3 We do not advocate routine neurosurgical intervention, as the natural history of acute narcotic encephalopathy varies from case to case. 2,13,20,21,24,34 If indicated, the timing of neurosurgical treatment should be based on serial clinical and radiological findings. We believe that an absolute indication to intervene is progressive cerebellar edema/ stroke, especially if there is newly developed hydrocephalus and brainstem compression, as documented in the case presented in this report.…”