A patient who inhales heroin vapor ("chasing the dragon") is at risk for a toxic leukoencephalopathy. Alambyan et al reported criteria for making the diagnosis. The authors are from Case Western Reserve University, the University of Minnesota, and the University of Arizona.
Inclusion criteria:
(1) clinical syndrome consistent with leukoencephalopathy
(2) positive toxicology screen for heroin
(3) confirmed report of heroin inhalation (from patient, family, witness)
(4) imaging studies consistent with leukoencephalopathy
(5) histopathologic evidence of spongioform encephalopathy
Exclusion criteria (for a possible or probable diagnosis):
(1) exposure to a drug or toxin other than heroin capable of causing a toxic leukoencephalopathy
(2) evidence of an alternative diagnosis: infection, vascular, demyelination, paraneoplastic syndrome, radiation
(3) imaging studies showing predominantly cortical involvement with sparing of subcortical areas and the posterior fossa
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Inclusion Criteria
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Exclusion Criteria
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Category
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all 5 present
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NA
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definite
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criteria 1 to 4
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none present
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probable
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criteria 1 to 3
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none present
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possible
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criteria 1 to 4 with polysubstance or polyroute heroin abuse
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none present
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possible
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where:
• A positive toxicology screen for heroin needs to demonstrate the specific metabolite 6-MAM (6-monoacetylmorphine). This may be present in the urine for only a short time after use. Hair testing may be an alternate testing substrate.
