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Case Report
Chasing the Dragon”: A Fatal Case Report of Toxic Leucoencéphalopathie Due to Inhaled Heroin
Chasing the Dragon”: A Fatal Case Report of Toxic Leukoencephalopathy Due to Inhaled Heroin
Sergio Andrés Ochoa-Orozcoa,b,
Corresponding author
saochoa@utp.edu.co

Corresponding author. Teléfono de contacto: 3185471811.
, Julio César Gutiérrez-Seguraa,b, Ana María Coral-Leitonc, Efraín Alberto Trejos-Orozcob, Óscar Iván Gutiérrez-Sanjuánd, Julián David Carvajal-Guevaraa,b
a Departamento de Psiquiatría, Universidad Tecnológica de Pereira, Colombia
b Grupo de Investigación Psiquiatría, Neurociencia y Comunidad, Universidad Tecnológica de Pereira, Colombia
c Servicio de Psiquiatría, Hospital San Rafael, Pasto, Colombia
d Servicio de Medicina Interna, Universidad Tecnológica de Pereira, Colombia
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Leukoencephalopathy is the structural damage of cerebral white matter due to the destruction of myelin&#46; Multiple conditions may lead to leukoencephalopathy&#44; such as genetic disorders&#44; primary demyelinating diseases&#44; infections&#44; metabolic disorders&#44; brain trauma &#40;diffuse axonal damage&#41;&#44; and vascular diseases&#44; among others&#59;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a> although toxins remain as a prevalent and disabling cause&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Toxic leukoencephalopathy &#40;TL&#41; is caused by the exposure of a wide variety of agents including environmental toxins&#44; toluene&#44; cranial irradiation&#44; substance abuse or medications such as chemotherapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3&#44;4</span></a> TL may be due to idiosyncratic reaction as well as dose or time exposure related&#46; TL prevalence remains unknown&#44; and it is considered a rare entity&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">However&#44; an over increasing frequency has been reported due to industrial chemicals use&#44; chemotherapy&#44; or psychoactive substances abuse&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2&#44;4</span></a> Inhaled heroin use has been associated with the incidence of TL since the 1980s&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> Brain damage mechanism remains unknown&#44; but some suspected hypothesis include toxins derived from heroin molecular modification induced by heating&#44; or and hypoxic-ischemic pathology&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6&#44;7</span></a> In the present report&#44; we present a fatal case of TL in a young man with inhaled heroin consumption&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Case Presentation</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 28 years-old man from the urban area of Pereira &#40;Colombia&#41; was admitted to the emergency department presenting a rapid and progressive onset of asthenia&#44; adynamia&#44; dizziness&#44; disorientation&#44; muscle weakness and ataxic gait&#44; installed over the past two weeks&#46; He had no medical or surgical record&#44; except for substance abuse such as marijuana and cocaine since he was 15 years old&#46; He reported inhaled heroin use over the last two years&#44; with an increasing pattern in the last six months&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">He was admitted in regular physical conditions&#44; emaciated&#44; distractible&#44; with hypomimia&#44; bradylalia&#44; bradypsychia&#44; fluctuating akinetic mutism&#44; abulia&#44; with apathy&#44; impaired immediate memory&#44; slowness of movement&#44; hypotonia&#44; slightly decreased generalized muscle strength and ataxic gait&#46; Osteotendinous reflexes were normal and no Babinski sign was found&#46; Hemodynamics parameters were stable&#44; and no signs of respiratory difficulty were reported&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Total blood count showed mild leukocytosis&#46; The other laboratory tests &#40;urinary function&#44; blood gases&#44; serum sodium&#44; infectious diseases test such as HIV&#44; syphilis&#44; hepatitis B virus&#44; and hepatitis C virus&#41; were unremarkable&#46; Cranial computed tomography scan &#40;CT&#41; showed spread white matter &#40;WM&#41; hypodense images located at the semi-oval centers&#44; posterior limb of the internal capsules&#44; corticospinal aces&#44; occipital regions&#44; and cerebellum&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Brain magnetic resonance &#40;MR&#41; revealed hypointense lesions in T1 sequences&#44; hyperintense and symmetric T2 sequence lesions in WM at the semi-oval centers&#44; basal nuclei&#44; corticospinal tracts&#44; cerebellum&#44; the posterior area of the corpus callosum as well as in mesencephalic and bulbar regions &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; The patient worsens three days after admission&#44; with neurological impairment&#44; stupor&#44; hemodynamic instability&#44; respiratory failure&#44; and death&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">After the patient died&#44; the family signed the informed consent to use the clinical and radiological records to present and publish the case for scientific and academic purposes&#44; conserving the privacy and identity of the patient out of the record&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Literature Review</span><p id="par0045" class="elsevierStylePara elsevierViewall">WM covers approximately half of the brain and it is composed of multiple intra and interhemispheric tracts&#46; WM dysfunction due to myelin damage may produce neuropsychiatric symptoms such as distractibility&#44; memory impairment&#44; personality changes&#44; psychosis&#44; mood changes&#44; and dementia&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> TL must be considered in patients with neurobehavioral deficit who were exposed to toxins or substances&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Heroin &#40;diacetylmorphine&#41; is a semisynthetic drug&#44; derived from morphine and originated from the poppy <span class="elsevierStyleItalic">&#40;Papaver somniferous&#41;&#44;</span> first synthesized in the late 19<span class="elsevierStyleSup">th</span> century and initially emerged as antitussive medicine&#46; Heroin quickly showed great addictive potential&#44; so it was labeled as an illicit substance&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">&#8220;Chasing the Dragon&#8221; is the popular name given to inhaled heroin consumption&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> When heated on aluminum folds&#44; heroin becomes a reddish-brown gelatinous substance that releases a thick&#44; white smoke that resembles a dragon tail&#46; This smoke is &#8220;pursued&#8221; or inhaled through a straw or a tubular structure&#46; This technique is also called &#8220;Chinese blow&#8221;&#46; This practice was recognized for the first time in Hong Kong in the 1950s&#44; but nowadays it has been extended to users all over the world&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Despite inhaled heroin consumption is frequent&#44; and the association with TL is known&#44; it has rarely been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a> The first and largest outbreak of TL associated with the use of inhaled heroin was reported in 1982 in the Netherlands&#44; including 47 cases&#44; of which 11 died&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> Since 1982&#44; sporadic cases have been reported in Taiwan&#44; Hong Kong&#44; the United States&#44; and China&#44; among others<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5&#44;10-12</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Autopsies from TL patients associated with the use of inhaled heroin reveal spongiform degeneration&#44; the formation of vacuoles in the oligodendroglia and myelin sheaths&#44; with demyelination of the brain&#44; cerebral stem&#44; cerebellum&#44; and spinal cord&#59; these findings are called spongiform leukoencephalopathy<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">12&#44;13</span></a> Pyrolysate&#44; a compound resulting from the combustion of heroin&#44; seems to be responsible for cerebral damage<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6&#44;10</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In a German study carried out in 2014&#44; eight death patients due to heroin TL showed increased serum lactate&#44; suggestive of cerebral hypoxia&#59; increased choline&#44; suggestive of axonal compromise&#59; and decreased n-acetyl-aspartate&#44; suggestive of mitochondrial dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> Image findings in the TL include a compromise of symmetrical dentate nuclei&#44; cerebellum&#44; cerebral WM with bilateral symmetric hypersignal in the posterior limb of the internal capsule&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">13&#44;14</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Heroin TL progress through three stages&#46; Initial symptoms include motor restlessness&#44; apathy&#44; bradyphrenia&#44; and cerebellar ataxia&#46; In the second stage&#44; there is worsening of cerebellar symptoms&#44; hyperactive deep tendon reflexes&#44; myoclonic jerks&#44; and hypertonia&#46; In the final stage&#44; manifestations include stretching spasms&#44; diaphoresis&#44; fever&#44; hypotonia&#44; areflexia&#44; and akinetic mutism&#44; and in some cases death&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">10-12</span></a> Heroin TL mortality ranges between 23 and 25&#37;&#44; and death occurs mainly due to respiratory failure&#46; There is no effective treatment for TL<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">10-12</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">United Nations Office on Drugs and Crime reported that&#44; worldwide&#44; approximately 5&#37; of the global adult population has used drugs at least once&#44; in the lifetime&#44; another 0&#46;6&#37; suffered from drug use disorders &#40;SUD&#41;&#46; About 28 million years of &#8220;healthy life&#8221; were lost worldwide in 2015 because of premature death and disability caused by SUD&#46; Opioids&#44; including heroin&#44; remain the most harmful drugs and are responsible for 70&#37; of the SUD global burden&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">In Colombia&#44; there were about 32 thousand people consuming heroin in 2013&#44; with an expected increase to date&#46; Medellin&#44; Cali&#44; Pereira&#44; and Armenia are the more affected cities by the heroin-related disorders&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">16&#44;17</span></a> In this epidemiological context&#44; patients with TL due to heroin consumption&#44; just like this clinical case&#44; will be more frequently seen at emergency departments and psychiatric institutions&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusions</span><p id="par0090" class="elsevierStylePara elsevierViewall">Inhaled heroin consumption is a risk factor for TL&#44; with severe neurological compromise and high disability and death risk&#46; Since heroin consumption is becoming more frequent&#44; and there have been identified methadone treatment barriers&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a> this may be considered a public health issue&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">It&#39;s necessary to improve programs focused on heroin consumption prevention&#44; consequences treatment&#44; and elimination of the barriers to getting adequate treatment alternatives&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of Interests</span><p id="par0100" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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            2 => "Colombia"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Leukoencephalopathy is a myelin disorder caused by multiple agents&#44; including substance abuse&#46; A 28-year-old man arrived at the emergency department having suffered from asthenia&#44; dizziness&#44; disorientation and ataxia for two months&#46; He had a two-year history of heroin inhalation&#46; He arrived in a normal physical condition&#46; Brain magnetic resonance showed bilateral diffuse hypointense lesions in the white matter&#46; At day 3 after admission&#44; he presented neurological deterioration&#44; stupor&#44; haemodynamic instability&#44; respiratory failure&#44; and died&#46; Toxic leukoencephalopathy symptoms start with inattention&#44; memory and personality changes&#44; and may eventually cause dementia and death&#46; Heroin inhalation is a common practice and can lead to leukoencephalopathy&#46; Leukoencephalopathy associated with heroin inhalation is a rare entity that mainly affects young adults and has a high social impact&#46; Its aetiology is unclear&#44; it has no effective treatment and there is a high mortality rate&#46; Heroin consumption is on the rise in Colombia&#44; so TL should be considered by medical staff&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La leucoencefalopat&#237;a es una patolog&#237;a de la mielina producida por m&#250;ltiples agentes&#44; incluidas las sustancias de abuso&#46; Un var&#243;n de 28 a&#241;os lleg&#243; urgencias por 2&#160;meses de astenia&#44; mareo&#44; desorientaci&#243;n y ataxia&#46; Ten&#237;a antecedentes de consumo inhalado de hero&#237;na por 2&#160;a&#241;os&#46; Presentaba condiciones f&#237;sicas regulares&#46; La resonancia magn&#233;tica cerebral mostr&#243; lesiones hipointensas difusas bilaterales en la sustancia blanca&#46; Al tercer d&#237;a present&#243; empeoramiento de su estado neurol&#243;gico&#44; estupor&#44; inestabilidad hemodin&#225;mica&#44; insuficiencia respiratoria y muerte&#46; Los s&#237;ntomas de leucoencefalopat&#237;a t&#243;xica &#40;LT&#41; comienzan con falta de atenci&#243;n&#44; cambios en la memoria y la personalidad&#44; y finalmente demencia y muerte&#46; El consumo de hero&#237;na inhalada es una pr&#225;ctica frecuente con riesgo de que produzca LT&#46; La leucoencefalopat&#237;a asociada con el uso de hero&#237;na inhalada es una entidad rara que afecta principalmente a adultos j&#243;venes y tiene un alto impacto social&#46; Su etiolog&#237;a no est&#225; clara&#44; no tiene un tratamiento efectivo y tiene altas tasas de mortalidad&#46; El consumo de hero&#237;na est&#225; aumentando en Colombia&#44; por lo que el personal m&#233;dico debe tener en cuenta la LT&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Este caso fue presentado en la modalidad de <span class="elsevierStyleItalic">short oral presentation</span> en el <span class="elsevierStyleItalic">18</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">th</span></span><span class="elsevierStyleItalic">WPA World Congress of Psychiatry&#44;</span> en Ciudad de M&#233;xico&#44; entre el 27 y el 30 de septiembre de 2018&#46;</p>"
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                            0 => "G&#46; Mathey"
                            1 => "M&#46; Michaud"
                            2 => "S&#46; Pittion-Vouyovitch"
                            3 => "M&#46; Debouverie"
                          ]
                        ]
                      ]
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                  ]
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                      "Revista" => array:2 [
                        "tituloSerie" => "Revue neurologique&#46;"
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                      "titulo" => "The expanding prominence of toxic leukoencephalopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "C&#46;M&#46; Filley"
                            1 => "B&#46;V&#46; McConnell"
                            2 => "C&#46;A&#46; Anderson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "C&#46;M&#46; Filley"
                            1 => "B&#46; Kleinschmidt-DeMasters"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
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                      "LibroEditado" => array:3 [
                        "editores" => "C&#46;de Medeiros Rimkus, C&#46;S&#46;Andrade, C&#46;da Costa Leite, A&#46;M&#46;McKinney, L&#46;T&#46;Lucato"
                        "titulo" => "Toxic leukoencephalopathies&#44; including drug&#44; medication&#44; environmental&#44; and radiation-induced encephalopathic syndromes&#44; Seminars in Ultrasound&#44; CT and MRI"
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                      "titulo" => "Leucoencephalopathy after inhaling &#8220;heroin&#8221; pyrolysate"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "E&#46;C&#46; Wolters"
                            1 => "F&#46; Stam"
                            2 => "R&#46; Lousberg"
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                  "contribucion" => array:1 [
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                      "titulo" => "Pathology of toxic leucoencephalopathy in drug abuse supports hypoxic-ischemic pathophysiology&#47;etiology"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46; Alturkustani"
                            1 => "L&#46;C&#46; Ang"
                            2 => "D&#46; Ramsay"
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                      "doi" => "10.1111/neup.12377"
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                      "titulo" => "Increased densities of nitric oxide synthase expressing neurons in the temporal cortex and the hypothalamic paraventricular nucleus of polytoxicomanic heroin overdose victims&#58; possible implications for heroin neurotoxicity"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "H&#46;-G&#46; Bernstein"
                            1 => "K&#46; Tr&#252;bner"
                            2 => "P&#46; Krebs"
                          ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.acthis.2013.07.006"
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