Chasing the wrong dragon: A new presentation of heroin-induced toxic leukoencephalopathy mimicking anoxic brain injury

Abstract

Toxic leukoencephalopathy associated with heroin inhalation has been extensively described in the literature. This syndrome is characterized by progressive motor symptoms and dysautonomia that develop over weeks to months. We present three cases of abrupt-onset inhaled heroin-associated toxic leukoencephalopathy, a previously undescribed entity. These likely represent a subset of ''found down'' patients with acute neurologic changes not attributable to hypoxemic encephalopathy. All three had magnetic resonance imaging findings characteristic of toxic leukoencephalopathy, which has a relatively favorable prognosis. Prolonged unresponsiveness in patients ''found down'' after heroin overdose is often attributed to hypoxic brain injury. Brain magnetic resonance imaging is not generally included as part of routine workup. It should, however, be considered in patients with suspected inhaled heroin use due to the relatively favorable prognosis of toxic leukoencephalopathy. This is especially relevant in the setting of the current opioid epidemic and related increase in overdose-related intensive care unit admissions. The result may have significant impact on decisions about therapeutic options or continuation of care.

Malignant cerebellar edema in three-year-old girl following accidental opioid ingestion and fentanyl administration

“…First, unlike the acute edema seen in children, ''chasing the dragon'' syndrome usually presents over weeks to months after prolonged exposure, 26 although some cases with more acute onsets have been reported. 27,28 Second, the syndrome follows opioid inhalation rather than ingestion. 26 Histopathology examinations have revealed the presence of spongiosis with massive astrogliosis.…”

An Atypical Presentation of Heroin Inhalation Induced Leukoencephalopathy (Chasing the Dragon)

“…Heroin inhalation causing leukoencephalopathy was first initially described in a report from the Netherlands [ 1 ]. Inhaled heroin has become increasingly popular to avoid the risk of diseases associated with parenteral administration of heroin Heroin and its metabolite cross the blood-brain barrier after inhalation.…”

“…Leukoencephalopathy, due to heroin inhalation colloquially known as 'chasing the dragon,' is a rare complication of heroin abuse. 'Chasing the dragon' a term derived from the method of inhalation of heroin fumes that is different from sniffing or smoking heroin [ 1 ]. A small amount of heroin powder is heated in aluminum foil, which then releases a white smoke resembling a dragon tail.…”

Predicting the outcome of a comatose patient at the bedside

“…Awakening does occur despite severe white-matter disease on MRI, and even cognition can substantially improve. Nevertheless, prolonged stays in an intensive care unit with tracheostomy and gastrostomy and prolonged gait rehabilitation are common 46 47. Atypical alcohol ingestion (ie, methanol found in commercial products such as windshield washer fluids, deicers, antifreeze, paints, wood stains and glass cleaners) is very problematic and often lethal.…”