Leukoencephalopathy due to inhalational and trans-conjunctival heroin abuse: First case report from Pakistan

and importance: Heroin-induced leukoencephalopathy (HLE) is a rare illness that causes diffuse white matter destruction, leading to acute or subacute development of neurological signs and symptoms. Physicians must be aware of the likely clinical presentation to properly evaluate and diagnose this clinical entity.

We report the case of a young gentleman who presented with acute stupor following his first instance of heroin vapor inhalation. He later confessed to trans-conjunctival application of the drug as well. His Glasgow Coma Scale (GCS) score improved within four days of admission, however, the neurologic sequalae such as cognitive impairment, spastic paraparesis and urge incontinence only partially resolved at three months. Abnormal white matter hyperintensities with restricted diffusion on brain magnetic resonance imaging and history of heroin abuse led to diagnosis of toxic leukoencephalopathy.

Leukoencephalopathy with heroin is mostly observed after inhalation (i.e., "chasing the dragon") but other routes of abuse have also been reported. Although a large spectrum of presentations exists, altered mental status, cerebellar dysfunction and fecal/urinary incontinence are the most commonly seen presenting features. Anti-oxidant therapy has shown promising results in terms of treatment.

The growing rates of opioid use disorders require physicians to be aware of and counsel the patients regarding dangerous neurological sequelae of these drugs.