Fatal methadone intoxication in a child

Natural history of pediatric morphine leukoencephalopathy on CT and MRI

An increased awareness of opioids and the imaging appearance in opioid overdose-related leukoencephalopathy has rapidly become crucial with respect to its identification by emergency radiologists. It is a potentially life-threatening condition and is associated with devastating neurological outcomes. Thus, early diagnosis and management are paramount. We report a rare case of toxic leukoencephalopathy in a 20-month-old male patient secondary to morphine overdose in the outpatient setting following discharge from uncomplicated urethroplasty. Although pediatric toxic leukoencephalopathy has been reported previously in the literature, our case report is unique as it involves morphine, a less commonly used opioid in the outpatient setting. Moreover, we have provided brain computed tomography and magnetic resonance imaging and highlighted findings in the acute and chronic stages of the disease trajectory. This case report highlights the importance for radiologists, especially those involved in emergency care, to have a high index of suspicion for toxic leukoencephalopathy, a potentially devastating but treatable condition.

Neuroimaging Findings in CHANTER Syndrome: A Case Series

Recently, a distinct clinicoradiologic entity involving cerebellar, hippocampal, and basal nuclei transient edema with restricted diffusion (CHANTER) on MR imaging was identified. Patients present in an unresponsive state following exposure to drugs of abuse. Very little information exists regarding this entity, particularly in the radiology literature. We identify and describe 3 patients at our institution with similar clinical and radiographic findings. Multifocal restricted diffusion in the brain is typically associated with poor outcomes. By contrast, CHANTER involves intraventricular obstructive hydrocephalus that, when treated, can lead to substantial recovery. This novel syndrome should be on the differential in patients who present in an unresponsive state after recent opioid use in the context of the above imaging findings. Additional diagnoses on the differential can include ischemic stroke, hypoxic-ischemic encephalopathy, "chasing the dragon," leukoencephalopathy, opioid-associated amnestic syndrome, and pediatric opioid-use-associated neurotoxicity with cerebellar edema.

Acute Cerebellitis and Atypical Posterior Reversible Encephalopathy Syndrome Associated with Methadone Intoxication

We report a case of a 9-year-old boy who presented with altered mental status and ataxia following 3 days of vomiting. Shortly after arrival to our emergency department, he declined and required intubation. The following day, he recovered and was successfully extubated. He was found to be positive for methadone on his urine drug screen. Brain imaging demonstrated a pattern of acute cerebellitis. Following extubation, the patient returned to his normal mental status; however, he began to have consistently elevated blood pressure and bradycardia and subsequent brain imaging showed supratentorial changes that were related to atypical posterior reversible encephalopathy syndrome. Through medical management including high-dose steroids and antihypertensive medications, the patient's blood pressure normalized, and he was eventually discharged home without further complications.

Methadone-induced encephalopathy: a case series and literature review

BACKGROUND

Accidental ingestion or consumption of supra-therapeutic doses of methadone can result in neurological sequelae in humans. We aimed to determine the neurological deficits of methadone-poisoned patients admitted to a referral poisoning hospital using brain magnetic resonance (MR) and diffusion weighted (DW) imaging.

METHODS

In this retrospective study, brain MRIs of the patients admitted to our referral center due to methadone intoxication were reviewed. Methadone intoxication was confirmed based on history, congruent clinical presentation, and confirmatory urine analysis. Each patient had an MRI with Echo planar T1, T2, FLAIR, and DWI and apparent deficient coefficient (ADC) sequences without contrast media. Abnormalities were recorded and categorized based on their anatomic location and sequence.

RESULTS

Ten patients with abnormal MRI findings were identified. Eight had acute- and two had delayed-onset encephalopathy. Imaging findings included bilateral confluent or patchy T2 and FLAIR high signal intensity in cerebral white matter, cerebellar involvement, and bilateral occipito-parietal cortex diffusion restriction in DWI. Internal capsule involvement was identified in two patients while abnormality in globus pallidus and head of caudate nuclei were reported in another. Bilateral cerebral symmetrical confluent white matter signal abnormality with sparing of subcortical U-fibers on T2 and FLAIR sequences were observed in both patients with delayed-onset encephalopathy.

CONCLUSIONS

Acute- and delayed-onset encephalopathies are two rare adverse events detected in methadone-intoxicated patients. Brain MRI findings can be helpful in detection of methadone-induced encephalopathy.

Opioid-induced toxic leukoencephalopathy: A case report and review of the literature

Importance

Reports of toxic leukoencephalopathy (TLE) due to opioids have been extensively documented within the adult literature. There is a paucity of literature with respect to the incidence, complications, and outcomes of TLE in the pediatric population.

Objective

To describe a rare complication of opioid ingestion in the pediatric population and serve as the first large review of published cases of opioid-induced leukoencephalopathy. Thirteen case reports with varying treatments are herein reviewed in addition to our own case. The range of treatment modalities, morbidity and mortality are broad and outcomes secondary to supportive care versus neurosurgical intervention is explored.

Evidence review

All cases of pediatric opioid-induced toxic leukoencephalopathy published on pubmed and google scholar were included in this review.

Findings

We report the case of a 4-year old male surgically treated for acute oxycodone-induced TLE who initially presented with Glascow Coma Scale of 4 and a comatose state for weeks. Over the next several months he recovered with spasticity of all extremities, oral aversion, substantial vision loss, and the ability to speak in short sentences. In addition, we found thirteen other reported cases of opioid-induced leukoencephalopathy reported in the literature. The treatment approaches described range from supportive care alone, to invasive neurosurgical interventions including placement of extraventricular drains, removal of hemorrhagic tissue, and craniectomy. The outcomes of patients with opioid-induced leukoencephalopathy is also variable. Reports demonstrate a range of outcomes that include patients who died to those with no residual neurologic deficits.

Conclusions

This review of reported pediatric cases of opioid-induced leukoencephalopathy highlights the importance of early neurosurgical intervention for prevention of devastating outcomes.

Malignant cerebellar edema in three-year-old girl following accidental opioid ingestion and fentanyl administration

A three-year-old girl was found altered with an unknown timeline. Gas chromatography mass spectrometry was positive for hydromorphone, dihydrocodeine, and hydrocodone. Initial computed tomography and magnetic resonance imaging suggested a malignant cerebellar edema not confined to a vascular distribution. She received fentanyl boluses on hospital days 0 and 1 before receiving a continuous infusion on day 1. On day 3, she had an episode of acute hypertension and bradycardia. Emergent computed tomography showed an evolving hydrocephalus and similar diffuse edema throughout both cerebellar hemispheres. External ventricular drain was placed to relieve the increased intracranial pressure. Following drain placement and fentanyl discontinuation, the patient recovered, though not without fine- and gross-motor deficits at the four-month follow-up. Our case adds to a handful of case reports of opioid toxicity in pediatric patients that present as toxic leukoencephalopathy. Though the mechanism is poorly understood, it has been suggested to be a consequence of the neurotoxic effects of the drug, which has particular affinity for µ opioid receptors-the primary opioid receptor found in the cerebellum. Clinicians would do well to recognize that this syndrome is primarily caused by direct toxicity rather than ischemia. This case adds insight by suggesting that lipophilic opioid analgesics may worsen this neurotoxicity. When intervening with mechanical ventilation, clinicians should consider avoiding lipophilic opioid drugs for analgesia until the pathogenesis of cerebellar edema is better understood.

Malignant Cerebellar Edema Subsequent to Accidental Prescription Opioid Intoxication in Children

We present two recent cases of toddlers who developed malignant cerebellar edema subsequent to accidental ingestion of prescription opioids. Both children presented acute neurological decline, hydrocephalus, and tonsillar herniation requiring emergent ventricular drain placement, suboccipital craniectomy, and partial cerebellectomy. Together with several other reports, these cases suggest the existence of an uncommon yet severe syndrome of acute opioid-induced malignant cerebellar edema. We hypothesize that the condition results from a combination of primary opioid receptor-mediated changes in neuronal metabolism that are exacerbated by secondary hypoxic insult. If recognized promptly, this syndrome can be treated with emergent neurosurgical intervention with good clinical outcomes. These cases also illustrate the unintended consequences and innocent victims of the spiraling prescription opioid epidemic, which will likely increase in prevalence. Recognition of this syndrome by clinicians is thus critical.

Therapeutic and recreational methadone cardiotoxicity

Several classes of drugs have been associated with an increased risk of cardiovascular disease and occurrence of arrhythmias potentially involved in sudden deaths in chronic users even at therapeutic doses. The study presented herein focuses on pathological changes involving the heart possibly due to methadone use. 60 cases were included in the study in total and were divided into three groups (therapeutic methadone users: 20 cases, recreational methadone users: 20 cases, and sudden death group in subjects who had never taken methadone: 20 cases). Autopsies, histology, biochemistry and toxicology were performed in all cases. Macroscopic and microscopic investigation results in therapeutic methadone users were similar to those observed in sudden, unexpected deaths in non-methadone users. In recreational methadone consumers, macroscopic and microscopic examination of the heart failed to provide results consistent with acute or chronic myocardial or coronary damage, thereby corroborating the hypothesis of death most likely following respiratory depression.

Opioid overdose in a child: case report and discussion with emphasis on neurosurgical implications

In environments in which opioids are increasingly abused for recreation, children are becoming more at risk for both accidental and nonaccidental intoxication. In toxic doses, opioids can cause potentially lethal acute leukoencephalopathy, which has a predilection for the cerebellum in young children. The authors present the case of a 2-year-old girl who suffered an accidental opioid overdose, presenting with altered mental status requiring cardiorespiratory support. She required emergency posterior fossa decompression, partial cerebellectomy, and CSF drainage due to cerebellar edema compressing the fourth ventricle. To the authors' knowledge, this is the first report of surgical decompression used to treat cerebellar edema associated with opioid overdose in a child.

Are empty methadone bottles empty? An analytic study

BACKGROUND

Methadone maintenance treatment is the most widely prescribed treatment for opiate dependence with proven benefits for patients. In naïve users or in case of recreational misuse, methadone can be a source of potentially lethal intoxications, resulting in fatal overdoses. A few cases of infantile intoxications have been described in the literature, some of which resulted in death. Nowadays, more than 50,000 bottles are used every day in France, most of which are thrown away in the bin. Relatives at home, especially children, can have access to these empty bottles. This study aims to determine whether the residual quantity of methadone in the bottles is associated with a risk of intoxication for someone who has a low tolerance to opiates, such as a child.

METHODS

The methadone dosage left in a sample of 175 bottles recapped after use by the patients taking their maintenance treatment in an addiction treatment program centre was analysed during a 2-week period in March 2013.

RESULTS

The mean residual quantity of methadone left in each bottle after use is 1.9 ± 1.8 mg and 3.3 ± 2.4 mg in the sample of 60 mg bottles.

CONCLUSIONS

There is a potential danger of accidental overdose with empty bottles of methadone syrup, especially for children. To take into account this hazard, several harm reduction strategies can be proposed, such as favouring the taking of the treatment within the delivery centres rather than the 'take home' doses, asking methadone users to bring back their used bottles, and raising patients' awareness of the intoxication risks and the necessary everyday precautions. For stable patients with take home methadone, the use of capsules could be considered.

Use of hair testing to determine methadone exposure in pediatric deaths

A case of death attributed to methadone acute poisoning in an infant aged 11 months is reported. A sudden infant death syndrome (SIDS) was suspected, whereas a traumatic cause of death was excluded regarding autopsy findings. Specimens were submitted to a large toxicological analysis, which included ethanol measurement by HS-GC-FID, a targeted screening for drugs of abuse and various prescription drug classes followed by quantification using UPLC-MS/MS methods. Methadone and its metabolite (EDDP) were detected in all the tested fluids, as well as in hair, with a blood concentration of methadone considered as lethal for children (73 ng/mL). The cause of death was determined to be acute "methadone poisoning", and the manner of death was "accidental". A discussion of the case circumstances, the difficulties with the interpretation of toxicological findings in children (blood concentration and hair testing), and the origin of exposure are discussed.

Methadone-induced delayed posthypoxic encephalopathy: clinical, radiological, and pathological findings

Objective. To describe the clinical, radiological and pathological findings in a patient with methadone-induced delayed posthypoxic encephalopathy (DPHE). Case Report. A Thirty-eight-year-old man was found unconscious for an unknown duration after methadone and diazepam ingestion. His initial vitals were temperature 104 degree Fahrenheit, heart rate 148/minute, respiratory rate 50/minute, and blood pressure 107/72 mmhg. He developed renal failure, rhabdomyolysis, and elevated liver enzymes which resolved completely in 6 days. After 2 weeks from discharge he had progressive deterioration of his cognitive, behavioral and neurological function. Brain MRI showed diffuse abnormal T2 signal in the corona radiata, centrum semiovale, and subcortical white matter throughout all lobes. Extensive work up was negative for any metabolic, infectious or autoimmune disorder. Brain biopsy showed significant axonal injury in the white matter. He was treated successfully with combination of steroids and antioxidants. Follow up at 2 year showed no residual deficits. Conclusion. Our observation suggests that patients on methadone therapy should be monitored for any neurological or psychiatric symptoms, and in suspected cases MRI brain may help to make the diagnosis of DPHE. A trial of steroids and antioxidants may be considered in these patients.

A delayed methadone encephalopathy: clinical and neuroradiological findings

Several studies on opiates demonstrated that selected brain areas as cerebellum and limbic system have the greatest density of opioid receptors. Recently, few cases of severe cerebellitis following methadone poisoning have been reported in children. We present the case of a 30-month-old girl who developed a delayed encephalopathy after methadone intoxication. She was admitted to our emergency department in coma, and after naloxone infusion, she completely recovered. Five days after intoxication, she developed psychomotor agitation, slurred speech, abnormal movements, and ataxia despite a negative neuroimaging finding. A repeat magnetic resonance imaging (MRI) performed 19 days after the intoxication for persistent symptoms showed signal abnormalities in the temporomesial regions, basal ganglia, and substantia nigra. To our knowledge, this is the first report of these delayed MRI findings associated with synthetic opioid intoxication.

Parental substance abuse and accidental death in children

In this report, the authors present two cases of accidental death in children of addicted parents. In the first case, the child was left unattended at home while the mother went out to buy cocaine. She was arrested and detained with no mention of the unsupervised child. The cause of death in this case was determined to be starvation and dehydration. In the second case, a child mistakenly received a methadone suppository by her father instead of an antipyretic suppository. Toxicological analysis of the femoral blood revealed methadone at a concentration of 1.2 mg/L. The cause of death was determined to be methadone intoxication. The literature is reviewed and discussed. We report these cases to illustrate the risk of harm to children from illicit drugs and prescription medications at home and because there is no mention of accidental death in children following a methadone suppository administration in the current literature.

Methadone-induced toxic leukoencephalopathy: MR imaging and MR proton spectroscopy findings

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.

Accidental methadone ingestion in an infant: case report and review of the literature

INTRODUCTION

We discuss accidental methadone intoxication in an 11-month-old female infant, review the literature, and stress the potential for child abuse among methadone-maintained caregivers.

CASE

An 11-month-old female infant presented with lethargy. Vital signs were normal, and pupils were constricted. Sepsis workup revealed no evidence of bacterial infection. High venous pCO2 suggested respiratory acidosis. Urine toxicology revealed high concentrations of methadone and its metabolites, and the diagnosis of methadone intoxication was confirmed when 0.1 mg/kg intravenous naloxone normalized the child's behavior. Social service agency inquiries found that the child's grandfather had been prescribed methadone for acquired morphine addiction. He carried 5-mg methadone tablets in his pocket and had recently babysat the infant. The patient was subsequently discharged home with pediatric and community services follow-up.

DISCUSSION

Methadone intoxication should be considered in children presenting with lethargy, miosis, and respiratory depression. Seventy-two percent of reported methadone poisoning patients are symptomatic, and unintentional poisoning is a real danger to children because small amounts can be fatal. There are also several case reports where the cause of intoxication was homicide by the parents. Initial management consists of establishing an airway, and naloxone may be indicated, before urine toxicology results are obtained, to help establish the diagnosis. However, if 2 doses do not reverse the child's symptoms, the diagnosis should be questioned. When repeated bolus doses of naloxone are indicated, a continuous infusion may be preferable.