Disclosures: Sidney O. Okon, MS4: No financial relationships or conflicts of interest

Case Diagnosis: Leukoencephalopathy Secondary to Heroin Inhalation

Case Description or Program Description: The patient is a 30-year-old female with known history of substance use disorder who presented with complaints of slurred speech and difficulty walking. She admitted to inhaling heroin every morning. Initial MRI showed hyperintensity throughout the supratentorial and infratentorial white matter. On exam, she showed moderate cognitive and linguistic impairments with mild dysarthria and word finding difficulty, along with mild non-specific weakness in the upper and lower extremities, severe ataxia bilaterally, and an unsafe gait. She was able to ambulate with assist 200ft. Over the course of 12 days, she continued to decompensate displaying rapidly decreasing truncal control, decorticate posturing, impairment of fine motor coordination, and akathisia of the lower extremities. Repeat MRI showed abnormality in the basal ganglial region, temporal lobe white matter, and pons.

Setting: Inpatient Rehabilitation

Assessment/Results: She eventually was unable to move the upper extremities and had increasing difficulty breathing and swallowing. She was transferred to hospice where she passed.

Discussion (relevance): The patient’s history of heroin inhalation, also known as “chasing the dragon”, presenting with motor restlessness and ataxia followed by a rapid neurologic decline and characteristic MRI findings point towards heroin inhalation induced leukoencephalopathy. This is an exceedingly rare condition with one review in 2018 finding only 88 documented cases. There is no proven treatment for this condition, and presentation with severe symptoms results in death in over half of cases.

Conclusions: Heroin inhalation induced leukoencephalopathy is an extremely rare complication of heroin abuse. Given its grim prognosis, physiatrists should be cognizant of the social support available to the patient, as they will likely need extensive assistance in the rehabilitation process. If a severe case is suspected, expectations should be addressed with the patient and family and an earlier consultation to palliative care should be obtained.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/leukoencephalopathy-secondary-to-heroin-inhalation-a-noteworthy-consideration/