Abstract: Although rare, toxic leukoencephalopathy (TLE) associated with heroin inhalation have been reported. ‘Chasing the dragon’ may lead to progressive spongiform degeneration of the brain and presents with a large range of neuropsychological sequelae. A thorough social history and clinical suspicion are paramount in recognizing the diagnosis. This case is an example of TLE in a middle-aged white male with a history of polysubstance abuse. He presented with a three week history of progressive neuropsychological symptoms, including abulia, bradyphrenia, hyperreflexia, and visual hallucinations. He was initially suspected to have progressive multifocal leukoencephalopathy, however, JCV PCR was negative. MRI showed diffuse abnormal signal in the white matter, extending into the thalami and cerebral peduncles. Brain biopsy was performed, which revealed spongiform degeneration, and a diagnosis of TLE was made. The patient was then transferred to a skilled nursing facility. Clinical suspicion based on a thorough history and clinical exam findings is paramount in recognition of heroin-associated TLE. Although rare, heroin-inhalation TLE continues to be reported, particularly amongst inhalational users. As ‘chasing the dragon’ is gaining popularity among drug users, it is important for clinicians to be able to recognize this disease process.
Conflict(s) of Interest
References with DOI
1. Wolters EC et al. Leucoencephalopathy after inhaling "heroin" pyrolysate. Lancet. 1982; 2(8310):1233-7. https://doi.org/10.1016/s0140-6736(82)90101-5
2. Singh R and Saini M. Toxic leukoencephalopathy after ‘chasing the dragon.’ Singapore Med J. 2015; 56(6):e102-104. https://doi.org/10.11622/smedj.2015094
3. Kriegstein AR et al. Leukoencephalopathy and raised brain lactate from heroin vapor inhalation (“chasing the dragon”). Neurology. 1999; 53(8):1765-73. https://doi.org/10.1212/wnl.53.8.1765
4. Cinque P et al. Diagnosis of central nervous system complications in HIV-infected patients: cerebrospinal fluid analysis by the polymerase chain reaction. AIDS. 1997; 11(1):1. https://doi.org/10.1097/00002030-199701000-00003
5. Buxton JA et al. Chasing the dragon - characterizing cases of leukoencephalopathy associated with heroin inhalation in British Columbia. Harm Reduct J. 2011; 8:3. https://doi.org/10.1186/1477-7517-8-3
6. Kriegstein AR et al. Heroin inhalation and progressive spongiform leukoencephalopathy. N Engl J Med. 1997; 336(8):589. https://doi.org/10.1056/nejm199702203360818
7. Heales S Crawley F et al. Reversible parkinsonism following heroin pyrolysate inhalation is associated with tetrahydrobiopterin deficiency. Movement Disorder. 2004; 19(10):1248-51. https://doi.org/10.1002/mds.20158
8. Schutte C M et al. Heroin-induced toxic leukoencephalopathy – “chasing the dragon” in South Africa. Drugs and Alcohol Today. 2017; 17 (3): 195-99. https://doi.org/10.1108/dat-09-2016-0023
9. Tormoehlen LM. Toxic Leukoencephalopathies. Psychiatric Clinics of North America. 2013; 36 (2): 277-92. https://doi.org/10.1016/j.ncl.2011.05.005
Cho, Daniel Young; Nazha, Hani; and Fisher, Kalin
"Chasing The Dragon,"
Marshall Journal of Medicine:
1, Article 3.
Available at: https://mds.marshall.edu/mjm/vol4/iss1/3