Leucoencephalopathy following abuse of sniffed heroin

doi:10.1016/j.jocn.2016.09.023

Journal of Clinical Neuroscience

Volume 35, January 2017, Pages 70-72

https://doi.org/10.1016/j.jocn.2016.09.023 Get rights and content

Highlights

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Heroin-induced leucoencephalopathy is a rare condition.
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Heroin-induced leucoencephalopathy excluding cerebellum and brainstem is rare.
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This pattern seems to concern patients that use heroin by sniff or injection.
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Imaging and clinical patterns can indicate the mode of drug administration.

Abstract

A 29-year-old man was admitted for acute cognitive impairment. Three weeks earlier, he had been admitted for coma due to sniffed heroin abuse responsive to naloxone infusion. At admission, the patient presented with apraxia, severe memory impairment and anosognosia. Brain MRI revealed symmetric hyperintensities of supratentorial white matter, sparing brainstem and cerebellum, on FLAIR and B1000 sequences. Four months later, repeated neuropsychological assessment revealed dramatic improvement of global cognitive functions.

Toxic leucoencephalopathy excluding the cerebellum and brainstem is a rare complication of heroin abuse, and seems to concern especially patients that use heroin by sniff or injection. In these patients, cognitive troubles are predominant, prognosis seems better and infratentorial brain structures can be spared.

In conclusion, our observation emphasizes that heroin-induced encephalopathy can have a favourable outcome and that imaging and clinical patterns can indicate the mode of drug administration.

Introduction

Heroin-induced leucoencephalopathy is a rare condition despite numerous heroin consumers. We report the case of a patient having delayed severe encephalopathy after heroin sniffed abuse with favourable outcome and discuss the specificity of brain MRI images.

Section snippets

Case report

A 29-year-old man was admitted for acute cognitive impairment. His medical history was: active tobacco smoking, cannabis, alcohol and heroin abuse for many years, depression and several suicide attempts. Three weeks earlier, he had been admitted for coma due to sniffed heroin abuse responsive to naloxone infusion. He had presented no hypoxia and endotracheal intubation had not been necessary. Pneumopathy consecutive to the coma had been diagnosed and amoxicilline/clavulanic acid (3 g per day for

Discussion

Heroin-induced leucoencephalopathy is an infrequently encountered toxic leucoencephalopathy which was first reported by Wolters et al. in 1982 [2]. Classic presentation of heroin-induced leucoencephalopathy occurring in patient inhaling heroin, also known as “chasing the dragon”, includes severe motor and cerebellar involvement, poor prognosis and symmetric typical infratentorial radiological findings. Indeed, involvement of the cerebellar and posterior cerebral white matter including the

Authors contributions

Romain Lefaucheur: acquisition of data, analysis and interpretation, critical revision of the manuscript for important intellectual content.

Axel Lebas: acquisition of data, analysis and interpretation, critical revision of the manuscript for important intellectual content.

Emmanuel Gérardin: acquisition of data, analysis and interpretation.

Lou Grangeon: acquisition of data, analysis and interpretation.

Ozlem Ozkul-Wermester: acquisition of data, analysis and interpretation.

Carole Aubier-Girard:

Acknowledgment

We thank Dr A. Lebas for his help to create brain MRI figure with his software JimboDicomviewer.

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Among the forensic autopsy studies, data were not available on the timing of the overdose and the subjects’ death. Thirteen subjects were reported to have fully recovered during the follow-up window, which ranged from three days to one year (Carroll et al., 2012; Cerase et al., 2011; Cohen and Hack, 2019; Corre et al., 2013; Huisa et al., 2013; Koch et al., 2018; Lefaucheur et al., 2017; Long et al., 2013; Meyer, 2013; Molloy et al., 2006; Mumma et al., 2009; Vila and Chamorro, 1997; Zamora et al., 2015). Sixteen had a partial recovery at follow-up, which ranged from three to nine months (Arciniegas et al., 2004; Barnett et al., 2001; Beeskow et al., 2018; Bileviciute-Ljungar et al., 2014; Cheng et al., 2019; Chang et al., 2009; Gupta et al., 2009; Jasne et al., 2019; Landais, 2014; Salazar and Dubow, 2012; Shprecher et al., 2008; Switzer et al., 2020; Vendrame and Azizi, 2007; Villella et al., 2010).
Non-fatal opioid-related overdoses have increased significantly over the past two decades and there have been increasing reports of brain injuries and/or neurocognitive impairments following overdose events. Limited preclinical research suggests that opioid overdoses may cause brain injury; however, little is known about such injuries in humans. The purpose this systematic review is to summarize existing studies on neurocognitive impairments and/or brain abnormalities associated with an opioid-related overdose in humans.
PubMed, Web of Science, Ovid MEDLINE and PsyINFO were searched, without year restrictions, and identified 3099 articles. An additional 24 articles were identified by reviewing references. Articles were included if they were published in English, reported study findings in humans, included individuals 18 years of age or older, and reported an objective measure of neurocognitive impairments and/or brain abnormalities resulting from an opioid-related overdose. Six domains of bias (selection, performance, attrition, detection (two dimensions) and reporting were evaluated and themes were summarized.
Seventy-nine journal articles, published between 1973–2020, were included in the review. More than half of the articles were case reports (n = 44) and there were 11 cohort studies, 18 case series, and 6 case-control studies. All of the studies were categorized as at-risk of bias, few controlled for confounding factors, and methodological differences made direct comparisons difficult. Less than half of the studies reported toxicology results confirming an opioid-related overdose; 64.6 % reported brain MRI results and 27.8 % reported results of neuropsychological testing. Only two studies had within subject comparative data to document changes in the brain possibly associated with an overdose. Despite these limitations, existing publications suggest that brain injuries and neurocognitive impairments are associated with opioid overdose. Additional research is needed to establish the incidence of overdose-related brain injuries and the potential impact on functioning, as well as engagement in treatment of substance use disorders.
Respiratory depression is a defining characteristic of opioid overdose and prolonged cerebral hypoxia may cause brain injuries and/or neurocognitive impairments. The onset, characteristics, and duration of such injuries is variable and additional research is needed to understand their clinical implications.
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ATL secondary to “chasing the dragon” was first reported in 1982 when an epidemiologic study connected patients in the Netherlands with spongiform leukoencephalopathy to inhalational use of a single source of heroin.9 Since then, other methods of heroin, cocaine, toluene, and ethanol use have been associated with toxic leukoencephalopathy, but they have not been noted as frequently as cases secondary to inhalational heroin use.6,10 Patients appear to be at higher risk if they have used heroin for more than 3 years.11
“Chasing the dragon” is a method of heating heroin in aluminum foil and inhaling its fumes. This method of use comes with the risk of toxic leukoencephalopathy, a form of white matter disease that can lead to permanent cognitive impairment.
This report presents a patient with heroin-induced toxic leukoencephalopathy who showed substantial clinical improvement after trial of amantadine and antioxidant therapy.
This report highlights the presentation of heroin-induced leukoencephalopathy, a discussion of its management, and the potential synergistic effect of amantadine and antioxidant therapy.
Chasing the dragon: Leukoencephalopathy due to inhaled heroin use
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La leucoencefalopatía tóxica es una complicación por el consumo de heroína en forma inhalada. «Perseguir al dragón» es un método para calentar heroína sobre papel de aluminio e inhalar los humos resultantes al seguirlos o perseguirlos, un método preferido por su rápida biodisponibilidad, mayor facilidad de administración y un perfil infeccioso más seguro en comparación con el uso de drogas inyectables.
Se presenta el caso de un hombre adolescente con historial de abuso de varias sustancias, incluida la heroína inhalada, y posterior aparición de síndrome cerebeloso progresivo. En la resonancia magnética se observó leucoencefalopatía sobresaliendo el compromiso cerebeloso. Se diagnosticó leucoencefalopatía tóxica por heroína inhalada. El paciente ingresó en un programa de rehabilitación y más adelante tuvo mejoría parcial de los síntomas y de los hallazgos neurológicos.
En los últimos años se ha visto un incremento en este diagnóstico de egreso, posiblemente por un aumento de esta forma de consumo, sin embargo, la literatura al respecto es limitada, lo que contribuye a la inexperiencia del personal de salud al enfrentarse al diagnóstico y manejo oportuno de un paciente con esta patología.
Toxic leukoencephalopathy is a complication caused by the consumption of heroin in inhaled form. “Chasing the dragon” consists of heating heroin on aluminum foil and inhaling the resulting fumes by following or “chasing” after them. This is a preferred method because of its rapid bioavailability, easier administration, and a safer infectious profile compared to the use of injectable forms.
We present the case of a young adult with a history of abuse of multiple substances, including heroin in inhaled form, and later, the appearance of progressive cerebellar syndrome. Magnetic resonance imaging revealed leukoencephalopathy with cerebellar involvement. Toxic leukoencephalopathy caused by inhaled heroin was diagnosed. The patient entered a multidisciplinary rehabilitation program, which later partially improved his symptoms and neurological findings.
In recent years there has been an increase in this type of discharge diagnosis, possibly due to an increase in this form of consumption. However, the literature in this field is scarce. This directly leads to a lack of experience in health personnel that are attempting to diagnose and treat a patient with this pathology.
“Chasing the Dragon”: A Fatal Case Report of Toxic Leucoencéphalopathie Due to Inhaled Heroin
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Leukoencephalopathy is a myelin disorder caused by multiple agents, including substance abuse.
A 28-year-old man arrived at the emergency department having suffered from asthenia, dizziness, disorientation and ataxia for two months. He had a two-year history of heroin inhalation. He arrived in a normal physical condition. Brain magnetic resonance showed bilateral diffuse hypointense lesions in the white matter. At day 3 after admission, he presented neurological deterioration, stupor, haemodynamic instability, respiratory failure, and died.
Toxic leukoencephalopathy symptoms start with inattention, memory and personality changes, and may eventually cause dementia and death. Heroin inhalation is a common practice and can lead to leukoencephalopathy.
Leukoencephalopathy associated with heroin inhalation is a rare entity that mainly affects young adults and has a high social impact. Its aetiology is unclear, it has no effective treatment and there is a high mortality rate. Heroin consumption is on the rise in Colombia, so TL should be considered by medical staff.
La leucoencefalopatía es una patología de la mielina producida por múltiples agentes, incluidas las sustancias de abuso.
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La leucoencefalopatía asociada con el uso de heroína inhalada es una entidad rara que afecta principalmente a adultos jóvenes y tiene un alto impacto social. Su etiología no está clara, no tiene un tratamiento efectivo y tiene altas tasas de mortalidad. El consumo de heroína está aumentando en Colombia, por lo que el personal médico debe tener en cuenta la LT.
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Case reportLeucoencephalopathy following abuse of sniffed heroin