Methadone-Induced Toxicity-An Unexpected Challenge for the Brain and Heart in ICU Settings: Case Report and Review of the Literature

Abstract

Introduction: Methadone, a synthetic opioid used for opioid substitution therapy (OST), is typically associated with arrhythmias rather than direct myocardial depression. Neurological complications, especially with concurrent antipsychotic use, have also been reported. Acute left ventricular failure in young adults is uncommon and often linked to genetic or infectious causes. We present a rare case of reversible cardiogenic shock and cerebellar insult due to methadone toxicity.

Case presentation: A 37-year-old man with a history of drug abuse on OST with methadone (130 mg/day) was admitted to the ICU with hemodynamic instability, seizures, and focal neurological deficits. Diagnostic workup revealed low cardiac output syndrome and a right cerebellar insult, attributed to methadone toxicity. The patient received individualized catecholamine support. After 10 days in the ICU, he was transferred to a general ward for ongoing cardiac and neurological rehabilitation and discharged in stable condition seven days later.

Conclusions: Methadone-induced reversible left ventricular failure, particularly when accompanied by cerebellar insult, is rare but potentially life-threatening. Early recognition and multidisciplinary management are essential for full recovery in such complex toxicological presentations.

Keywords: brain insult; cardiogenic shock; left ventricular failure; methadone; multidisciplinary care; opioid substitution therapy.

Figure 1

Brain CT showing right cerebellar insult (arrow).

Figure 2

Echocardiographic findings (apical four-chamber view) at admission that revealed a grade III mitral regurgitation and mildly dilated left ventricle. The color scale reveals red tones for the blood approaching the transducer and blue tones for the blood moving away from the transducer.

Figure 3

ECG tracing revealing prolonged QTc and signs of ischemia in the anterior limbs (aVL, V1–V4) (left) Coronary angiography showed no abnormalities (right).

Figure 4

Chest X-ray revealing moderate pulmonary congestion.

Figure 5

Chest X-ray showing no signs of pulmonary congestion or consolidation.

Figure 6

Hemodynamic evolution during vasopressor and inotrope weaning. Cardiac Index (CI, L/min/m²) and Systemic Vascular Resistance Index (SVRI, dyn·s·cm⁻⁵·m²) are shown on the upper panel. Dobutamine and norepinephrine doses (μg/kg/min) are shown on the lower panel. D represents days of ICU stay.

Figure 7

Echocardiographic findings showing an LVEF of 60%.