Leukoencephalopathy and raised brain lactate from heroin vapor inhalation (“chasing the dragon”)

Kriegstein, Arnold R.; Shungu, Dikoma C.; Millar, William S.; Armitage, Beth A.; Brust, John C.M.; Chillrud, S. N.; Goldman, Jill; Lynch, Thomas G.

doi:10.1212/wnl.53.8.1765

Cited by 142 publications

(126 citation statements)

References 28 publications

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“…In the 1980s, "chasing the dragon," inhaling the thick white pyrosylate generated by heating heroin base on aluminum foil, was implicated in an unexplained spongiform encephalopathy in the Netherlands. Similar cases were reported in other parts of Europe and the USA [68,69]. Clinical features included abulia, ataxia, speech abnormalities, spastic paraparesis, and hypotonia with prominent cerebellar and cerebral white matter destruction on MRI [70,71].…”

Section: Case Continuationsupporting

confidence: 59%

Case Files of the New York City Poison Control Center: Paradichlorobenzene-Induced Leukoencephalopathy

2010

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A 44-year-old man was brought to the emergency department by emergency medical services after he was discovered lying supine on his apartment floor. He was accompanied by his sister, who had decided to visit him after his absence from a family function. Worsening "bizarre" behavior had been noted by family members for 4 weeks, characterized by anorexia, social withdrawal, flat affect, and alogia. Prior to his illness, he was described as functional, independent, gainfully employed, and social.The patient had mild mental retardation and hypertension. There was no history of diagnosed psychiatric illness, although his family suspected pica. Medications included an unknown antihypertensive with which he was not compliant. He occasionally used marijuana and alcohol, without history of other abused drugs. The patient's sister reported significant weight loss over several months. There had been no apparent fevers, cough, vomiting, diarrhea, or convulsions. On physical examination, he appeared drowsy, was markedly cachectic, and emanated an atypical aromatic body odor. Initial vital signs were: blood pressure 154/90 mmHg, heart rate 98/min, respiratory rate 20/min, rectal temperature 37.4°C, and room air oxygen saturation 97%. Head, neck, chest, and abdominal examinations were unremarkable. He had dry, scaling, and ichthyotic skin. He was oriented to person and place, but not to time, date, or indication for hospitalization. Limited cranial nerve evaluation was normal. Pain and light-touch sensation were unaffected. Hyperreflexia (without clonus) and cogwheel rigidity were noted in both lower extremities; upper extremities were normal. Plantar reflexes were normal bilaterally. Muscle bulk, tone, and strength were normal. The patient was unable to stand without support and unable to ambulate, apparently due to impaired equilibrioception. He could follow simple one-step commands. He would speak a few words when asked simple questions, and he avoided eye contact.Serum electrolytes (sodium, potassium, chloride, calcium, and magnesium) and serum glucose were normal. Tests of hepatic and renal function were: AST 53

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Section: Case Continuationsupporting

confidence: 59%

Case Files of the New York City Poison Control Center: Paradichlorobenzene-Induced Leukoencephalopathy

2010

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“…1 Most of the available literature on imaging of illicit substances deals with the neurotoxic changes induced by heroin, a morphine agonist, administered either intravenously or through (repeated) inhalation. [2][3][4][5][6][7] There are only a few reported cases of severe methadone-induced toxic leukoencephalopathy that include imaging findings. [8][9][10] The imaging findings in our patient are similar, though not identical, to previously reported MR imaging and spectroscopic white matter changes observed in heroin-vapor-inhalation toxicity (a practice known as "chasing the dragon").…”

Section: Discussionmentioning

confidence: 99%

Methadone-Induced Toxic Leukoencephalopathy: MR Imaging and MR Proton Spectroscopy Findings

Salgado¹,

Jorens²,

Baar³

et al. 2009

AJNR Am J Neuroradiol

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SUMMARY:We report the clinical, MR imaging, and proton MR spectroscopy findings in a middle-aged woman with proved methadone-induced toxic leukoencephalopathy. The imaging characteristics of this unusual condition have been reported only rarely in the medical literature. We show that the imaging findings in methadone-induced toxic leukoencephalopathy are similar, though not identical, to previously reported cases of neurologic deterioration due to heroin inhalation. ABBREVIATIONS:Cho ϭ choline; Cr ϭ creatine; FLAIR ϭ fluid-attenuated inversion recovery; NAA ϭ N-acetylaspartate

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“…brain MRI, brain biopsy) are usually performed, they are more useful in ruling out other pathologies and are not necessary for making the diagnosis, although they may be supportive. 1,3 In heroin-inhalation TLE, brain MRI typically shows diffuse, symmetrical white matter hyperintensities on T2 and FLAIR images in the cerebellum, posterior cerebrum, and posterior limbs of the internal capsule. Brain biopsy, when performed, usually shows spongiform degeneration with relative sparing of subcortical U-fibers.…”

Section: Discussionmentioning

confidence: 99%

“…Brain biopsy, when performed, usually shows spongiform degeneration with relative sparing of subcortical U-fibers. 3 There is no treatment for heroininhalation TLE, and mortality ranges between 23 and 48% of patients affected, with the most frequent cause of death being respiratory failure. 1,5 In rare cases, mild clinical improvement in symptoms has been noted with antioxidant therapy including coenzyme Q10, vitamin E, and vitamin C. 3,6 Surviving patients should be referred to physical and drug rehabilitation programs.…”

Section: Discussionmentioning

confidence: 99%

Chasing The Dragon

Cho¹,

Nazha²,

Fisher³

2018

MJM

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Leukoencephalopathy and raised brain lactate from heroin vapor inhalation (“chasing the dragon”)

Abstract: Elevated lactate in white matter and the possible response to antioxidants suggests mitochondrial dysfunction in progressive spongiform leukoencephalopathy following inhalation of heated heroin vapor.

Cited by 142 publications

References 28 publications

Case Files of the New York City Poison Control Center: Paradichlorobenzene-Induced Leukoencephalopathy

Case Files of the New York City Poison Control Center: Paradichlorobenzene-Induced Leukoencephalopathy

Methadone-Induced Toxic Leukoencephalopathy: MR Imaging and MR Proton Spectroscopy Findings

Chasing The Dragon

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