Toxic leukoencephalopathy in a 45-year-old female opioid user - Case Details

MRI

DWI MRI: Bilateral white matter hyperintensities.

T2 MRI: Supratentorial white matter hyperintensities.

T2-FLAIR MRI: Periventricular white matter hyperintensities sparing U-fibers.

Histopathology

H&E ×200: White matter vacuoles & astrogliosis.

H&E ×400: Vacuolization & microglial activation.

View Discussion

Title: Toxic Leukoencephalopathy in a 45-year-old Female Opioid User
Diagnosis Title: Toxic Leukoencephalopathy due to Opioid Use (Heroin/Morphine/Oxycodone)
Disease Specialty: Neurology
Ease of Diagnosis: Difficult
Certainty: Certain
Ethnicity: Asian
Segment: Adult Female
Image Quality: Medium
Clinical Examination: Patient is disoriented to time and place, oriented only to self, brushing teeth with a comb , responds only to simple commands, hyperreflexia (3+ patellar reflexes), wide-based gait, intact light touch and pain sensation, Cranial nerves: normal pupils, EOMs intact, palmomental reflex present bilaterally
Patient Age: 45 years
Patient Gender: Female

A 45-year-old female with a history of opioid use (morphine, oxycodone, heroin) presents with a 1-month history of altered mental status, bizarre behavior, and progressive cognitive decline. She had used opioids 2 months prior for 1 week, followed by a head injury 3 weeks later. Symptoms worsened over 1 month, including apraxia, aphasia, selective mutism, hyperreflexia, and wide-based gait. MRI brain showed bilateral white matter changes, and brain biopsy confirmed astrogliosis and microglial activation. The patient deteriorated rapidly and died 7 weeks after presentation.