(610) The Cost of "Chasing Dragons": Spongiform Leukoencephalopathy With Rhabdomyolysis

Introduction: ”Chasing the Dragon “refers to the method of inhaling heated heroin vapors over an aluminum foil. This practice has been associated with the development of a type of toxic leukoencephalopathy called heroin-associated spongiform leukoencephalopathy (HSL). Clinical presentation includes motor restlessness, pyramidal and pseudobulbar signs, spasms, and hypotonic paresis and can be lethal in one-quarter to one-third of cases. The current case highlights one of the grim facets of the opioid crisis

Description: 32 year old male was found drowsy following binge inhaling of heroin vapors over 5 days. His GCS at presentation to ER was 10/15 with dysarthria. Pupils were bilaterally equal, normal-sized, and reacting to light. Deep tendon reflexes were decreased and Babinski's sign was normal. Power was 3/5 in all limbs. Over the next 6 hours, his respiratory efforts and consciousness levels continued to decline despite multiple doses of Naloxone. He was intubated and managed in the ICU. The patient had quadriparesis with CK levels reaching up to 50,902 U/L with associated acute kidney injury. NCV-EMG studies were suggestive of the myopathic process. MRI brain showed areas of abnormal hyperintensities with hemorrhagic residues involving bilateral basal ganglia & cerebellar hemispheres. The patient was managed via supportive care and discharged after 23 days

Discussion: Heroin-induced rhabdomyolysis is commonly reported, HSL is an uncommon presentation. Even though it is mostly seen with heroin vapor use, it can also manifest when heroin is used via other routes. Mild cases usually cause pseudobulbar and cerebellar dysfunction, while more severe cases can also include hyperreflexia, spasticity, and spasms, leading to hypotonic paresis requiring mechanical ventilation. While the exact etiology remains unclear, unknown toxins, aluminum toxicity, and mitochondrial dysfunction are some of the proposed pathological causes. Neuroimaging reveals symmetric white matter hyperintensities on T2/Flair sequences involving both supra/infra tentorial compartments with characteristic distribution. With no definitive treatment, coenzyme Q10, Vitamin C, and E have shown benefit in anecdotal cases. This case provides a glimpse of this rare presentation of heroin use to the intensivist in the current opioid crisis