“Chasing the dragon” refers to inhalation of heroin vapor after heating on aluminum foil sheets. Inhalation is thought to bring “greater highs” from vapors immediately reaching the brain, leading to users chasing the feeling of euphoria. This method of usage has been reported to cause toxic leukoencephalopathy with predilection for the cerebellum. Pathophysiology involves accumulation of opioids into myelin sheaths leading to spongiform degeneration of white matter via oligodendrocyte vacuolization. We present an extremely rare case of fatal leukoencephalopathy with diffuse cerebral and cerebellar infarcts secondary to “chasing the dragon” with fentanyl. 

A 49-year-old woman presented after becoming acutely unresponsive following fentanyl vapor inhalation. Urine drug screen was positive for fentanyl. Serial CT head imaging revealed evolving bilateral cerebellar hypodensities. She was transferred to a tertiary-care center for neurology and neurosurgery evaluation. Shortly after arrival, she decompensated due to cerebral edema requiring emergent suboccipital craniotomy. Subsequent MRI brain confirmed extensive areas of acute infarction on diffusion-weighted imaging involving multiple vascular territories within deep white matter, brainstem, and cerebellum, with FLAIR sequencing demonstrating a pattern of widespread hyperintensity consistent with leukoencephalopathy. Despite aggressive measures, patient’s neurologic examination remained extremely poor. She was transitioned to comfort measures per family request and passed away shortly thereafter, with ultimate diagnosis of toxic leukoencephalopathy secondary to fentanyl inhalation.

Fentanyl is the deadliest of all opioids with overdose rates rising 2.5 times faster than those associated with heroin. It is important for neurologists to recognize potential neurological complications associated with fentanyl usage as the opioid epidemic continues to escalate. To our knowledge, fentanyl inhalation resulting in leukoencephalopathy has only ever been described in one previous case report. Our case highlights fentanyl inhalation as a potential cause of toxic leukoencephalopathy and offers an opportunity to raise awareness of this alternate cause of "chasing the dragon".