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A Case of Toxic Leukoencephalopathy: A Rare Toxicity of a Frequently Prescribed Medication FREE TO VIEW

Hayas Haseer Koya, MD; Dona Varghese, MD; Gaganjot Singh, MD; Dinesh Ananthan, MD
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SUNY Upstate Medical University, Syracuse, NY

Chest. 2014;146(4_MeetingAbstracts):282A. doi:10.1378/chest.1995237
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SESSION TITLE: Critical Care Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Toxic leucoencephalopathy can present with a wide range of neurobehavioral symptoms and is commonly associated with methadone and heroin intoxication. Oxycodone and oxycontin intoxication causing toxic leucoencephalopathy has been reported very rarely.

CASE PRESENTATION: A 44 year-old-male with past medical history of chronic low back pain was admitted because of disorganized thoughts and behavior. According to his family, the patient had been acting strangely since 2 weeks, which included going off on long walks at night without sleeping.On examination,he was found to have disoriention to time and place,disorganized thought process and slow speech with constricted affect, but with no neurological deficits. Initial lab studies were unremarkable. On the third day of hospitalization, he became delirious and developed hyperextension of the neck, but had no neurological deficits.He was started empirically on antibiotics which were discontinued when CSF studies came back negative. MRI brain revealed confluent restricted diffusion with associated T2 and FLAIR hyperintensity within bilateral periventricular and subcortical white matter,consistent with global hypoperfusion or toxic insult.Rest of the work up including vascular imaging and thyroid function were normal. Further probing into the patient's history revealed that the patient had been obtaining oxycodone and oxycontin from multiple health care providers for his back pain. He was also evaluated in a different hospital a week prior for his bizarre behavior at which time he had tested positive for opiates on urine drug screen.The patient was started on olanzapine,coenzyme Q and vitamin C. His symptoms improved with supportive care and getting him completely off oxycodone and oxycontin.Follow up visit a month later revealed complete resolution of symptoms with return of his personality to baseline.

DISCUSSION: Toxic leucoencephalopathy is a structural alteration of cerebral white matter especially those controlling higher cerebral function, causing a spectrum of clinical features from inattention, forgetfulness, changes in personality, dementia, coma and even death.Therapeutic agents like anticancer drugs, environmental toxins like carbon monoxide, drugs of abuse like cocaine, MDMA, heroin are commonly associated with toxic leucoencephalopathy. Diagnosis is usually based on history of exposure to toxin in addition to positive neuropsychological and neuroradiological testing.Treatment options are limited and include reduction of exposure to toxins,use of less toxic treatment regimens for cancer, chelation therapy for arsenic poisoning.

CONCLUSIONS: We emphasize the need for high index of suspicion for toxic leucoencephlopathy and careful history and review of medications,especially in patients with chronic pain syndromes, presenting with acute or chronic neurobehavioral deficits

Reference #1: Tormoehlen LM. Toxic leukoencephalopathies. Neurol Clin. 2011 Aug;29(3):591-605. doi: 10.1016/j.ncl.2011.05.005. Review

DISCLOSURE: The following authors have nothing to disclose: Hayas Haseer Koya, Dona Varghese, Gaganjot Singh, Dinesh Ananthan

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