Correspondence

Heroin Inhalation and Progressive Spongiform Leukoencephalopathy

N Engl J Med 1997; 336:589-590February 20, 1997

Article

To the Editor:

We report two cases of a progressive spongiform leukoencephalopathy that, to our knowledge, has not been reported previously in the United States. The disease occurred after the patients inhaled heated heroin vapor, a practice known as “chasing the dragon.”

In Patient 1, a 21-year-old woman with a six-month history of inhaling heroin vapor, progressive bradykinesia, ataxia, and slurred speech developed over a two-week period. She denied using intravenous drugs. On admission she had abulia. She followed simple, one-step commands, but there was a long period of latency before she initiated movements, which were slow and ataxic. She maintained a decorticate posture at rest, with normal tendon reflexes. Over the next two weeks she became mute, spastic, nearly quadriplegic, and unable to stand or sit.

Blood tests revealed traces of heroin, cocaine, and methadone. The results of serologic tests for the human immunodeficiency virus (HIV), routine analyses of serum chemistry, hematologic tests, and cerebrospinal fluid studies were normal. A computed tomographic scan showed diffuse lucency of the cerebellar and cerebral white matter. T₂-weighted magnetic resonance imaging (MRI) showed diffuse, symmetric areas of hyperintensity in the white matter of the cerebellum, the posterior cerebrum, the corticospinal tract, and the lemniscal pathway (Figure 1Figure 1Modified T₂-Weighted Spin–Echo MRI Scan of the Brain in Patient 1.). A brain biopsy revealed spongiform degeneration of the white matter, with relative sparing of subcortical fibers (U fibers).

Patient 2 was a 40-year-old musician with a six-month history of intranasal use of cocaine and heroin; he had inhaled heroin vapor daily with Patient 1 for two weeks, ending three weeks before admission. During the week before admission he had difficulty playing the drums and began bumping into furniture. He had dysarthric, scanning speech and saccadic-pursuit eye movements with ocular dysmetria. His arm movements were ataxic, with dysmetria, dysdiadochokinesia, and rebound. His gait was broad-based and ataxic. HIV serologic, hematologic, and cerebrospinal fluid studies were normal. Cerebral T₂-weighted MRI findings were similar to those in the first patient: diffuse, symmetric areas of white-matter hyperintensity most prominent in the cerebellum, but also involving the posterior cerebrum, the splenium of the corpus callosum, and the posterior limbs of the internal capsule. After treatment with ubiquinone (coenzyme Q; 300 mg four times daily), Patient 2 had clinical improvement.

Toxic heroin-induced progressive spongiform leukoencephalopathy has a characteristic pattern on MRI (Figure 1). An outbreak in the Netherlands in 1982 involved 47 people.2 Subsequent cases have been reported elsewhere in Europe.1,3-5 In all instances, the mode of ingesting heroin was to heat the powder on aluminum foil and inhale the vapor.1-5 There have been suspicions about possible contamination of small batches of the drug by an unknown substance that is activated by heating. The illness has no known treatment and a mortality rate of 25 percent.1-3,5 “Dragon chasing” is gaining popularity among drug abusers in the United States as a means of ingesting heroin that averts the risk of exposure to HIV. Unfortunately, the practice puts users at risk for toxic heroin-induced leukoencephalopathy.

Arnold R. Kriegstein, M.D., Ph.D.
Beth A. Armitage, B.A.
Peter Y. Kim, M.D., Ph.D.
Columbia University College of Physicians and Surgeons, New York, NY 10032

5 References

1. 1

   Tan TP, Algra PR, Valk J, Wolters EC. Toxic leukoencephalopathy after inhalation of poisoned heroin: MR findings. AJNR Am J Neuroradiol 1994;15:175-178
   Web of Science | Medline

2. 2

   Wolters EC, van Wijngaarden GK, Stam FC, et al. Leucoencephalopathy after inhaling “heroin“ pyrolysate. Lancet 1982;2:1233-1237
   CrossRef | Web of Science | Medline

3. 3

   Schiffer D, Brignolio F, Giordana MT, Mongini T, Migheli A, Palmucci L. Spongiform encephalopathy in addicts inhaling pre-heated heroin. Clin Neuropathol 1985;4:174-180
   Web of Science | Medline

4. 4

   Sempere AP, Posada I, Ramo C, Cabello A. Spongiform leucoencephalopathy after inhaling heroin. Lancet 1991;338:320-320
   CrossRef | Web of Science | Medline

5. 5

   Celius EG, Andersson S. Leucoencephalopathy after inhalation of heroin: a case report. J Neurol Neurosurg Psychiatry 1996;60:694-695
   CrossRef | Web of Science | Medline

Citing Articles (15)

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   Laura M. Tormoehlen. (2011) Toxic Leukoencephalopathies. Neurologic Clinics 29:3, 591-605
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   A. Büttner. (2011) Review: The neuropathology of drug abuse. Neuropathology and Applied Neurobiology 37:2, 118-134
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   Deepti Anbarasan, Paul Campion, Jonathan Howard. (2011) Drug-induced leukoencephalopathy presenting as catatonia. General Hospital Psychiatry 33:1, 85.e1-85.e3
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   Claudio Romani, Martina Pettinau, Paolo Dessalvi, Roberta Murru, Emanuele Angelucci. (2008) Unexpected CNS localization in M2 acute myeloid leukemia: A link with past heroin addiction?. American Journal of Hematology 83:8, 682-683
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   Apostolos Tsapas, Konstantinos Paletas, Efthymia Vlachaki, Eleni Bekiari, Constantine Spanos, Dimitrios Economidis. (2008) Eosinophilic pneumonia associated with heroin inhalation: a case report. Wiener klinische Wochenschrift 120:5-6, 178-180
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9. 9

   Marjolein G. Klous, Wim Van den Brink, Jan M. Van Ree, Jos H. Beijnen. (2005) Development of pharmaceutical heroin preparations for medical co-prescription to opioid dependent patients. Drug and Alcohol Dependence 80:3, 283-295
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10. 10

    Marjolein G. Klous, Alwin D.R. Huitema, Elisabeth J. Rook, Michel J.X. Hillebrand, Vincent M. Hendriks, Wim Van den Brink, Jos H. Beijnen, Jan M. Van Ree. (2005) Pharmacokinetic comparison of two methods of heroin smoking: ‘chasing the dragon’ versus the use of a heating device. European Neuropsychopharmacology 15:3, 263-269
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11. 11

    Alasdair S Robertson, Sanjiv Jain, Ross A O'Neil. (2001) Spongiform leucoencephalopathy following intravenous heroin abuse: Radiological and histopathological findings. Australasian Radiology 45:3, 390-392
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12. 12

    J. Neiman, H. M. Haapaniemi, M. Hillbom. (2000) Neurological complications of drug abuse: pathophysiological mechanisms. European Journal of Neurology 7:6, 595-606
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13. 13

    Zahida Khan, D. K. Watson. (2000) Heparin-induced skin necrosis. BJOG: An International Journal of Obstetrics and Gynaecology 107:10, 1315-1316
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14. 14

    A Büttner, G Mall, R Penning, S Weis. (2000) The neuropathology of heroin abuse. Forensic Science International 113:1-3, 435-442
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15. 15

    John C.M. Brust. (1998) ACUTE NEUROLOGIC COMPLICATIONS OF DRUG AND ALCOHOL ABUSE. Neurologic Clinics 16:2, 503-519
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