Clinical Reasoning:A 28-year-old IV drug user with bilateral basal ganglia and brainstem lesions

Abstract

A 28-year-old man presented with progressive lethargy and confusion over 2 days. He has a longstanding history of IV heroin use. His last use was 2 weeks ago, and he completed inpatient detoxification 2 days before admission. After he returned home from rehabilitation, his roommate noticed that he became increasingly confused. On the day of admission, he was febrile, unable to get out of bed, or speak, although he was able to nod yes and no to simple questions. He also lost urinary control.His medical history was significant for hepatitis C and cardiomyopathy, both presumed to be associated with IV drug use. His cardiac ejection fraction was 25% to 30% 8 months prior, and improved to 45% to 50% 3 months before admission. He refused to take all medications.On examination, the patient's temperature was 38.9°C, pulse 82, respiration 28, and blood pressure 206/83 mm Hg. His neck was supple. He was lethargic, confused, and was only able to partially follow simple, 1-step commands. His pupils were equal and fully reactive. His eyes tracked to voice in all directions. He had no facial asymmetry but had moderate drooling. His right upper and lower extremities appeared to be weaker compared with the left. He withdrew to painful stimuli equally in all extremities. There was no evidence of abnormal movements such as dystonia, chorea, tremor, or dysmetria. The right patella reflex was brisk compared with the left; deep tendon reflexes were otherwise normal. He had a right Babinski and left plantar flexion.

Acute Radiologic Manifestations of America’s Opioid Epidemic

“…Although the relationship is not entirely understood, the pathophysiology of toxic encephalopathy is thought to be due to oligodendrocyte apoptosis and microvascular dysregulation (41), with spongiform degeneration of the white matter (38). Differential considerations include other conditions that affect the deep white matter, such as infectious encephalitis (mucormycosis in an immunocompromised patient in particular) (42), acute disseminated encephalomyelitis, progressive multifocal leukoencephalopathy, posterior reversible encephalopathy syndrome, vasculitis, and demyelinating disease. However, the clinical history, including laboratory markers, and concordant imaging findings can suggest heroin-induced leukoencephalopathy.…”

Bilateral Cerebral Mucormycosis in an Immunocompetent Female

“…10,11 While the majority of cases are unilateral, few bilateral cases have been reported in immunocompromised individuals or patients with diabetes mellitus. [12][13][14][15] We report a case of bilateral cerebral mucormycosis with leptomeningeal involvement in an immunocompetent patient.…”