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Abstract Details

Delayed Neurologic Deterioration after Opioid Overdose - an Uncommon Result of a Common Problem
General Neurology
P7 - Poster Session 7 (8:00 AM-9:00 AM)
2-003
To review the differential and clinical course of an uncommon case of altered mental status, hypertonicity, hyperreflexia and tremor.  
A 52-year-old woman with a history of bipolar disorder, chronic pain, and substance use disorder presented with altered mental status. She was admitted 2.5 weeks prior for suspected opioid overdose after being found unconscious, recovered within a few days, and was discharged home. She returned with three days of progressive confusion, unsteady gait, and left-hand tremor. She was initially disoriented but awake and interactive with an otherwise normal neurologic exam aside from rest tremor. Over the course of days, her condition deteriorated, and she became non-verbal, was no longer tracking or following commands, and developed progressive hypertonicity and hyperreflexia.
N/A
CT Head and serum studies evaluating metabolic, toxic, autoimmune, and infectious etiologies were unremarkable. CSF had elevated protein (69.9), normal glucose (86), 1 nucleated cell, 0 RBC. EEG showed mild generalized slowing. MRI brain demonstrated diffuse, non-enhancing T2/FLAIR white matter hyperintensities with associated diffusion restriction. 

The patient’s condition was most consistent with delayed post-hypoxic leukoencephalopathy. This is classically seen after carbon monoxide toxicity, as well as other conditions where the brain experiences prolonged low-level hypoxia (e.g., opioid overdose). The course is bi-phasic, where the patient initially recovers to their neurologic baseline, then has a relapse of neurologic symptoms 1-4 weeks later. Symptoms include depressed mental status/coma, gait disturbance, akinetic mutism, tremor, rigidity, and hyperreflexia. It may be caused by white matter injury leading to delayed demyelination. Diffuse T2 white matter hyperintensities and diffusion restriction on MRI are pathognomonic. The prognosis is unclear; some make a full recovery within weeks, but many are left with permanent deficits.  

During the patient’s hospitalization there was no improvement in her neurologic exam and her family elected discharge to hospice care where she expired.  
Authors/Disclosures
Kathryn Zuchowski, MD
PRESENTER 		Dr. Zuchowski has received personal compensation in the range of $500-$4,999 for serving as a QOD and Neuro SAE question writer with 好色先生.
Aaron S. Bower, MD Dr. Bower has nothing to disclose.
Nicholas Blondin, MD (Smilow Care Center - Trumbull) Dr. Blondin has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Novocure, Inc.. Dr. Blondin has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Novocure, Inc..