Chasing the dragon: Case report of positive recovery from cocaine inhaled induced leukoencephalopathy

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Toxic encephalopathies can be mistaken for a psychiatric diagnostic, and can lead to death. A 36 year old male with past active cannabis and multiple substance consumption is found apathetic and mute. The CT scan being subnormal and urine tests negative, a psychotic state is first thought of. On the 7th day, incontinence, extrapyramidal symptoms and mute state appear. The patient is transferred to a neurology department. The MRI discovers supratentoriel leukoencephalopathy with necrosis of both pallidal nodes and bifrontal periventricular white matter. A toxicological hair analysis proves semi-recent consumption of heroin, cocaine and levamisole. Ten days later, the patient presents a non-reactive coma and breathing distress. A tracheotomy and gastrostomy are necessary. The coenzyme treatment is started. After 41 days, he is transferred awaken and conscious in a post-reanimation rehabilitation unit. On admission his clinical state shows a tetra-paresis, spasticity of lower limbs, hypertonia, inhibition of voluntary limb movements, mute state and neuro-vegetative crisis. Three months later, the patient still has a little ataxia on upper left limb with hypertonia. He can walk without any technical help, with a relative equilibrium. The speech and writing are recovered to his original level. Mild frontal cognitive impairments are found: concentration, dysexecutive syndrome (precipitation, speech initiative, flexibility, planning and logic), visual-constructive and working memory. The first presentation of the patients could have led to lose of chances. The diagnosis is mainly clinical and MRI based, as the toxicology tests are often negative due to the symptoms’ coasting, but hair test remains important. The prognostic of the patient was hard to give all along, but the recovery is impressive. The diagnosis led to a Coenzyme and vitamins treatment (in reanimation ward). Could it be a treatment to recommend to cocaine and heroin leukoencephalopathy? Can the reduction of symptoms at one month from first ones be of good prognosis?