Irrespective of the route of administration, heroin abuse is attributed to severe medical complications and a high risk for addiction. Complications of acute heroin insufflation vary greatly from epistaxis, anosmia, rhabdomyolysis, stroke, and transverse myelitis. Transverse myelitis is considered a rare but serious complication with associated long-term morbidity. Here we present a case of a 20-year-old male patient who presented with paraplegia hours after nasal insufflation of heroin, consuming Xanax, and smoking marijuana and was incidentally diagnosed with cervical transverse myelitis. Patients with a history of drug abuse who present with acute neurological symptoms such as limb paralysis, and reduced sensation, should raise concern for transverse myelitis. The clinical presentation of heroin associated myelopathy is equivocal and requires prompt recognition and treatment to minimizing long-term sequelae.

A 66-year-old male was found unresponsive and diagnosed with acute carbon monoxide poisoning, with pathognomonic findings on radiological imaging. During his first day's the patient underwent acute neurological deterioration; however, this was followed 2 weeks later with a subsequent improvement to near baseline. The improvement back to baseline was short-lived, and the patient quickly worsened and underwent neurological decompensation. These findings were consistent with delayed post hypoxic leukoencephalopathy, serious sequelae of carbon monoxide poisoning. This case report shows the importance of recognition of carbon monoxide toxicity and aims to improve accurate diagnosis of the sequelae that may follow using computed tomography and magnetic resonance imaging sequences, magnetic resonance spectroscopy in order to prevent or ameliorate further neurological decline.