“Chasing the Dragon”—Heroin-Associated Spongiform Leukoencephalopathy

Abstract

A 21-year-old male presented with acute ataxia. For 1 week, he became increasingly unbalanced, clumsy, and severely dysarthric. He sustained multiple falls and had difficulty walking. He admitted to inhaling heated heroin vapors twice in the past, the last time was 1 week prior to admission. His symptoms started acutely 24 h after that. He denied injecting heroin in the past as he had a known “needle phobia”. On examination, his speech was severely dysarthric. He demonstrated horizontal nystagmus and positive cerebellar signs bilaterally with inability to stand without assistance and falling backwards when unsupported. Serum toxicology screen was negative. MRI revealed symmetrical white matter hyperintensities with a “C-shaped” lesion in the deep cerebellar hemispheres compatible with edema (Figs. 1 and 2). There was a loss of cerebellar folia, with inferior displacement of bilateral cerebral tonsils, compatible with developing cerebellar herniation through the foramen magnum (Fig. 2). Bilateral hypointensities involving the posterior limbs of the internal capsules were remarkable (Fig. 3).