(598) Chasing the Dragon: A Case of Oxycodone-Associated Toxic Leukoencephalopathy

Introduction: Oxycodone-associated leukoencephalopathy is a disorder of the brain white matter that has been observed in patients with opioid overdose on very rare occasions. We present a case of toxic leukoencephalopathy (TL) in a patient who was found unresponsive after oxycodone overdose, with a concise description of the complicated medical course that followed.

Description: A 48-year-old gentleman was admitted to the intensive care unit after he was found unconscious for an unknown amount of time at home by his wife. Patient was found next to several empty bottles of Percocet and did not respond to naloxone, with urine drug screen positive for opioids and cocaine. It was unclear how many pills he had ingested. Patient was tachycardic, tachypneic, febrile and hypertensive with decerebrate posture that was prominent after stimulation. Patient was intubated and continued to have parasympathetic hyperactivity. Electroencephalogram (EEG) was unremarkable for seizures. Patient was also found to have rhabdomyolysis with creatine kinase > 40,000 U/L. Initial CT head findings were similar to posterior reversible encephalopathy syndrome (PRES) and lumbar puncture was unremarkable. MRI revealed extensive diffusion restriction in the white matter of bilateral supratentorial cerebral hemispheres, bilateral globus pallidus and bilateral cerebellar hemisphere, consistent with brain injury in TL. Patient continued to deteriorate and was unable to be extubated, leading to the placement of tracheostomy and a percutaneous endoscopic gastrostomy tube. Palliative team was involved given poor prognosis and a bleak chance of recovery. Eventually, discharge was planned to a long-term acute care facility.

Discussion: Toxic leukoencephalopathy (TL) was first described in 2001, with oxycodone-associated neurotoxicity being initially reported in 2010. Reportedly seen with heroine vapor inhalation, or ‘chasing the dragon’, a large range of commonly used illicit drugs has been observed to produce MRI white matter changes. In classic TL, as in our patient, changes are present in a symmetrical distribution. With opiate use rising, it is crucial to be aware of this clinical condition in any patient ‘found down’ with suspected overdose. However, understanding of the mechanism of this disorder remains elusive and incomplete.