Mimicking a Psychiatric Disorder: Heroin-Induced Leukoencephalopathy

Abstract

Toxic leukoencephalopathy is a rare cause of encephalopathy. We describe two cases of toxic leukoencephalopathy associated with opiate abuse where they were misdiagnosed and admitted to the psychiatric ward. In our case series, both patients presented with behavioral changes, restlessness, pressured speech, and cognitive impairment for which they were initially labeled as psychiatric patients and were treated as such. However, after an extensive workup to elucidate the etiology of alteration in mental status, toxic leukoencephalopathy associated with heroin abuse was found to be the culprit in both cases. Toxic leukoencephalopathy is a rare condition that can be caused by inhalation of heroin. Clinically, it may present with confusion, behavioral changes, extrapyramidal symptoms, generalized motor deficit, unresponsiveness and even death. Our cases highlight the importance of recognizing the psychiatric presentation of toxic leukoencephalopathy.

Keywords: chasing the dragon; heroin abuse; toxic leukoencephalopathy.

Figure 1. Brain MRI images demonstrate diffuse cortical and subcortical white matter diffusion restriction with corresponding FLAIR hyperintensities of the bilateral cerebral hemispheres

A-C; DWI sequences. D-F: T2-FLAIR sequence. FLAIR - fluid-attenuated inversion recovery; DWI - diffusion-weighted imaging

Figure 2. MRI images of the brain showing diffuse cortical and subcortical white matter FLAIR hyperintensity and diffusion restriction.

A-C: FLAIR sequence. D-F: DWI sequence. DWI - diffusion-weighted imaging; FLAIR - fluid-attenuated inversion recovery