Disclosures: Kyle Smith, MD: No financial relationships or conflicts of interest

Case Diagnosis: Delayed Toxic Leukoencephalopathy

Case Description or Program Description: A 49-year-old male accountant with history of depression, recent suicide attempt via opioid overdose, complicated by bilateral severe ulnar neuropathies, presented to clinic for 2 weeks of confusion, multiple falls, and concern for hypoxic ischemic encephalopathy (HIE). He had recently been evaluated by primary care and the emergency department for similar symptoms, diagnosed separately as gabapentin toxicity and functional neurologic disorder secondary to depression. A prior head CT revealed only nonspecific white matter hypodensities, thought to be due to microvascular disease.

Setting: Outpatient PM&R brain injury rehab clinic

Assessment/Results: Despite reportedly having initially returned to accounting work after his recent overdose, physical exam revealed great difficulty transitioning from sit to stand and very unsteady short distance ambulation. Cognitive screening demonstrated significant difficulties with Trails A and Clock Drawing, with poor initiation and comprehension in executing these tasks. An MRI of the brain was ordered and showed poorly-defined bilateral T2 signal enhancement involving the cerebral white matter, consistent with delayed toxic leukoencephalopathy (DTL), given his clinical history.

Discussion (relevance): DTL presents as toxic exposure and cerebral hypoxia with initial clinical stability, followed days to weeks later by functional and neurological decline with imaging evidence of diffuse white matter disease. Given the mechanism of initial injury and delayed onset of decline, DTL can easily be misattributed to other disorders that point to other etiologies. A careful history may help clinicians identify this syndrome and target appropriate treatments with more precision. Prognosis is favorable for recovery. This patient completed therapies and returned to driving and full time employment six weeks after initial evaluation.

Conclusions: Delayed toxic leukoencephalopathy is an important diagnostic consideration in opioid overdose with resulting cerebral hypoxia.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/delayed-toxic-leukoencephalopathy-following-opioid-overdose-a-case-report/