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Cañas CA, Posso-Osorio I, Rivera-Londoño R, Bolaños JD, Granados AM. Severe cerebral edema related to oral methadone: A case report and literature review. Heliyon 2024; 10:e26111. [PMID: 38390136 PMCID: PMC10881884 DOI: 10.1016/j.heliyon.2024.e26111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 01/13/2024] [Accepted: 02/07/2024] [Indexed: 02/24/2024] Open
Abstract
Introduction Opioids are widely used for pain management, and increased intracranial pressure (ICP) has been evidenced in some cases. We reported a patient with severe cerebral edema after initiating methadone and its complete resolution upon discontinuing the medication. Additionally, a review of the literature is made. Case report A 53-year-old woman patient with a history of systemic lupus erythematosus developed mechanic chronic lower back pain, refractory to conventional treatments. She presented improvement with oxycodone. She withdrew this medication due to a lack of supplies in her country (Colombia) and showed withdrawal symptoms. She consulted the emergency department, where oral methadone was started and symptom control was achieved. Three days after admission, she presented intense headaches and emesis. A brain CT scan was performed in which severe cerebral edema was appreciated. Methadone was discontinued, and neurological symptoms quickly disappeared. A follow-up brain CT scan was performed later, finding full resolution of the edema. Conclusion A case of severe cerebral edema associated with the initiation of oral methadone and its rapid resolution without neurological sequelae after its withdrawal is presented, clinicians must be attentive to this adverse event.
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Affiliation(s)
- Carlos A Cañas
- Universidad Icesi, CIRAT: Research Center in Rheumatology, Autoimmunity and Translational Medicine, Valle del Cauca, Cali, Colombia
- Fundación Valle del Lili, Rheumatology Unit, Valle del Cauca, Cra. 98 No. 18-49, Cali, 760032, Colombia
| | - Ivan Posso-Osorio
- Fundación Valle del Lili, Rheumatology Unit, Valle del Cauca, Cra. 98 No. 18-49, Cali, 760032, Colombia
- Universidad Icesi, Faculty of Health Sciences, Valle del Cauca, Cali, Colombia
| | | | - Juan D Bolaños
- Fundación Valle del Lili, Clinical Research Center, Cali, 760032, Colombia
| | - Ana M Granados
- Fundación Valle del Lili, Radiology Unit, Valle del Cauca, Cra. 98 No. 18-49, Cali, 760032, Colombia
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Limbu D, Rajkanna J, Abdelrahman M, Kamara J. A Case of Opiate-Induced Toxic Leukoencephalopathy in a Middle-Aged Woman. Cureus 2023; 15:e39113. [PMID: 37378134 PMCID: PMC10292096 DOI: 10.7759/cureus.39113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2023] [Indexed: 06/29/2023] Open
Abstract
Toxic leukoencephalopathy is a disorder characterized by the alteration of myelin in white matter tracts secondary to exposure to neurotoxic substances. Here we describe a case of a middle-aged woman who presented to the emergency department with a history of bizarre behaviour, speech abnormalities and generalised muscle stiffness caused due to recent opioid overdose. Further investigations and extensive neurological tests, including magnetic resonance imaging (MRI) scan of the brain, demonstrated features consistent with toxic leukoencephalopathy (TLE). The patient was managed conservatively with the care of a multidisciplinary team involving a dietician, physiotherapist and speech and language therapist. She showed gradual and slow but significant recovery following a period of neurorehabilitation. The clinical presentation of TLE varies but MRI typically shows diffuse bi-lateral white matter lesions. History of neurotoxin exposure, presenting clinical signs and symptoms and radiological findings are significant in making the diagnosis. Early recognition is crucial and can help optimize patient's recovery and prevent severe complications.
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Affiliation(s)
- Dipraj Limbu
- Acute Medicine, Peterborough City Hospital, Peterborough, GBR
| | - Jeyanthy Rajkanna
- Diabetes and Endocrinology, Peterborough City Hospital, Peterborough, GBR
| | | | - John Kamara
- Cardiology, Peterborough City Hospital, Peterborough, GBR
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Chan IYM, Syed R, Jurkiewicz MT. Natural history of pediatric morphine leukoencephalopathy on CT and MRI. Emerg Radiol 2022; 29:1055-1058. [PMID: 35948808 DOI: 10.1007/s10140-022-02084-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/02/2022] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Ian Y M Chan
- Children's Hospital, London Health Science Centre, London, ON, Canada. .,Department of Medical Imaging, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada. .,Department of Medical Imaging, University of Toronto, Toronto, ON, Canada.
| | - Raza Syed
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Michael T Jurkiewicz
- Children's Hospital, London Health Science Centre, London, ON, Canada.,Department of Medical Imaging, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
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Chen Y, Liu Q, Wang J, Li H, Zhang Y, Sun L, Liu J. Delayed Post-Hypoxic Leukoencephalopathy Following Nitrite Poisoning: A Case Report and Review of the Literature. Front Neurol 2022; 13:836844. [PMID: 35444604 PMCID: PMC9013800 DOI: 10.3389/fneur.2022.836844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/14/2022] [Indexed: 11/17/2022] Open
Abstract
Background Delayed post-hypoxic leukoencephalopathy (DPHL) is a demyelinating syndrome that occurs days to weeks after the brain has recovered from a coma. It is caused by the period of hypoxia and is characterized by mental disorders, extrapyramidal system symptoms, and motor changes. Common causes include cardiogenic shock, severe anemia, massive blood loss, and poisoning. Poisoning, mostly resulting from intoxication with carbon monoxide and several narcotic drugs, has been reported to be a cause of DPHL. There are only a few reports of DPHL due to nitrite poisoning in literature. We report DPHL in a patient following nitrite poisoning and a review of the literature in this context. Case Presentation A 64-year-old man presented with dizziness and nausea without vomiting. He later went into a coma after consuming a spare rib soup. After blood gas analysis, we suspected nitrite poisoning combined with metabolic acidosis, hypoxemia, and electrolyte imbalance. He gradually showed neurologic recovery to premorbid baseline after intravenous administration of methylene blue (40 mg) and symptomatic treatment. Two months later, the patient's cerebral magnetic resonance imaging (MRI) showed signs that are compatible with injury, with the patient in late stages of mental decline. Conclusion Nitrite poisoning can cause DPHL. There is a period of intermittent recovery between the time of poisoning and the development of DPHL, but the specific pathogenesis and treatment are still unclear.
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Affiliation(s)
- Yankun Chen
- Department of Neurology, Heze Municipal Hospital, Heze, China
| | - Qiumei Liu
- Department of Computed Tomography, Heze Municipal Hospital, Heze, China
| | - Jian Wang
- Department of Magnetic Resonance Imaging, Heze Municipal Hospital, Heze, China
| | - Hui Li
- Department of Urology, Heze Municipal Hospital, Heze, China
| | - Yousheng Zhang
- Department of Emergency, Heze Municipal Hospital, Heze, China
| | - Lingling Sun
- Department of Neurology, Heze Municipal Hospital, Heze, China
| | - Jianli Liu
- Department of Computed Tomography, Heze Municipal Hospital, Heze, China
- *Correspondence: Jianli Liu
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Posterior Reversible Encephalopathy Syndrome (PRES) in a Patient with Opioid Use Disorder. Case Rep Psychiatry 2021; 2021:9999481. [PMID: 34221530 PMCID: PMC8225411 DOI: 10.1155/2021/9999481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 05/20/2021] [Accepted: 06/01/2021] [Indexed: 01/19/2023] Open
Abstract
Posterior Reversible Encephalopathy Syndrome (PRES) is a characteristic clinical radiographic syndrome with diffuse structural alteration of cerebral white matter secondary to myelin damage with diverse and multifactorial etiologies. It can present with acutely altered mentation, somnolence or occasionally stupor, vision impairment, seizures, and sudden or chronic headaches that are not focal. The pathophysiology remains unclear, but mechanisms involving endothelial injury and dysregulation of cerebral autoregulation have been purported. We report the case of a 36-year-old male with a history of heroin use disorder, who was admitted to our hospital for opioid withdrawal. CT head without contrast and MRI with and without gadolinium showed significant white matter disease in both cerebral hemispheres and cerebellum. He was diagnosed with Posterior Reversible Encephalopathy Syndrome secondary to heroin use and managed on the medical floor in collaboration with the neurology team. His clinical symptoms improved and he was discharged after six weeks. To our knowledge, this case did not present with the risk factors for PRES reported in the literature. For patients with heroin use disorder who present with an altered mental status, PRES should be highly suspected. The diagnosis and management require collaboration between psychiatry and neurology.
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Wheaton T, Toll BJ, Breznak K, Da-Silva S, Melvin J, Misra A, Hwang SW. Opioid-induced toxic leukoencephalopathy: A case report and review of the literature. Heliyon 2019; 5:e03005. [PMID: 31879710 PMCID: PMC6920259 DOI: 10.1016/j.heliyon.2019.e03005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 09/30/2019] [Accepted: 12/05/2019] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Taylor Wheaton
- St Christopher's Hospital for Children, Department of Critical Care Medicine, 160 E Erie Ave, Philadelphia, Pennsylvania, 19134, USA
- Corresponding author.
| | - Brandon J. Toll
- Shriners Hospitals for Children-Philadelphia, Departments of Orthopaedic and Neurosurgery, 3551 N Broad St, Philadelphia, PA, 19140, USA
| | - Kara Breznak
- St. Christopher's Hospital for Children, Department of Neurosurgery, 160 Erie Avenue, Philadelphia, PA, 19134, USA
| | - Shonola Da-Silva
- Shriners Hospitals for Children-Philadelphia, Department of Critical Care, 3551 N Broad St, Philadelphia, PA, 19140, USA
| | - Joseph Melvin
- St. Christopher's Hospital for Children, Department of Neurology, 160 Erie Avenue, Philadelphia, PA, 19134, USA
| | - Amit Misra
- St Christopher's Hospital for Children, Department of Critical Care Medicine, 160 E Erie Ave, Philadelphia, Pennsylvania, 19134, USA
| | - Steven W. Hwang
- Shriners Hospitals for Children-Philadelphia, Departments of Orthopaedic and Neurosurgery, 3551 N Broad St, Philadelphia, PA, 19140, USA
- St. Christopher's Hospital for Children, Department of Neurosurgery, 160 Erie Avenue, Philadelphia, PA, 19134, USA
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Abstract
Neuropsychiatric disorders caused by toxic substances pose a great diagnostic challenge due to the large variety of changes caused in the central and peripheral nervous system. The pathogenetic mechanisms at work are multifaceted and partly not solved. In human drug abusers (cannabis, opiates, cocaine, amphetamines, methamphetamine and "designer drugs"), a broad spectrum of central nervous system alterations are observed including infarction, intracerebral and subarachnoidal hemorrhage, hypoxic-ischemic leukoencephalopathy, infections, neuronal loss, specific astroglial and microglial reaction patterns, and vascular changes, including the endothelial cell as well as the basal lamina.
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Affiliation(s)
- Serge Weis
- Division of Neuropathology, Department of Pathology and Neuropathology, Kepler University Hospital and School of Medicine, Johannes Kepler University, Linz, Austria.
| | - Andreas Büttner
- Department of Forensic Medicine, University of Rostock, Rostock, Germany
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Cadet JL, Bisagno V, Milroy CM. Neuropathology of substance use disorders. Acta Neuropathol 2014; 127:91-107. [PMID: 24292887 PMCID: PMC7453825 DOI: 10.1007/s00401-013-1221-7] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 11/20/2013] [Indexed: 01/23/2023]
Abstract
Addictions to licit and illicit drugs are chronic relapsing brain disorders that affect circuits that regulate reward, motivation, memory, and decision-making. Drug-induced pathological changes in these brain regions are associated with characteristic enduring behaviors that continue despite adverse biopsychosocial consequences. Repeated exposure to these substances leads to egocentric behaviors that focus on obtaining the drug by any means and on taking the drug under adverse psychosocial and medical conditions. Addiction also includes craving for the substances and, in some cases, involvement in risky behaviors that can cause death. These patterns of behaviors are associated with specific cognitive disturbances and neuroimaging evidence for brain dysfunctions in a diverse population of drug addicts. Postmortem studies have also revealed significant biochemical and/or structural abnormalities in some addicted individuals. The present review provides a summary of the evidence that has accumulated over the past few years to implicate brain dysfunctions in the varied manifestations of drug addiction. We thus review data on cerebrovascular alterations, brain structural abnormalities, and postmortem studies of patients who abuse cannabis, cocaine, amphetamines, heroin, and "bath salts". We also discuss potential molecular, biochemical, and cellular bases for the varied clinical presentations of these patients. Elucidation of the biological bases of addiction will help to develop better therapeutic approaches to these patient populations.
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Affiliation(s)
- Jean Lud Cadet
- NIDA Intramural Research Program, Molecular Neuropsychiatry Research Branch, NIDA/NIH/DHHS, 251 Bayview Boulevard, Baltimore, MD, 21224, USA,
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Abstract
A variety of neuropathological findings has been described in illicit drug abusers. The majority of these alterations result from the consequences of hypoxia-ischemia and from cerebrovascular diseases. Within the last few years, widespread morphological alterations of the cellular elements of the brain have been detected. These changes consist of neuronal loss, a numerical reduction of astrocytes, widespread axonal damage with concomitant microglial activation and reactive and degenerative changes of the cerebral microvessels. Based on various studies there is also concern that drug abusers develop neurodegeneration or Parkinsonism as they age. However, whether or to what extent neurodegeneration occurs in human drug abusers remains to be established. In the present paper a brief overview on the neuropathological changes in drug abuse is presented for the forensic pathologist/toxi-cologist with reference to the most pertinent literature.
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Affiliation(s)
- Andreas Büttner
- Forensic Pathology and the Director and Chair of the Institute of Legal Medicine at the Medical University of Rostock, Germany. Ethical Commission at the Medical University of Rostock
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