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2002 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 2002 Volume 6 Pages 53 ± 55
53
Heroin-induced leucoencephalopathy misdiagnosed as psychiatric illness GWEN M SAYERS, MARY C GREEN AND RICHARD E SHAFFER Northwick Park Hospital, Middlesex, UK
Correspondence Address Gwen M Sayers, BSc MB BCh FRCP, Consultant Physician and Honorary Clinical Senior Lecturer (Imperial College School of Medicine), Northwick Park Hospital, Watford Road, Midddlesex HA1 3UJ Tel: 0208 869 2579 Fax: 0208 8692241
Received 26 September 2001; revised 20 November 2001; accepted for publication 22 November 2001
We present a patient with a background of psychiatric illness who was admitted to hospital with neurological symptoms and signs. Although the organic cause of the neurological disorder was extremely uncommon and hence not readily diagnosed, the signs clearly did not accord with the preexisting psychiatric diagnoses. Nevertheless, several clinicians attributed the cause of the disorder to mental illness, or drug side-effects. It is possible that patients suffering from mental illness may be assessed differently, perhaps due to prejudgemen t by clinicians. (Int J Psych Clin Pract 2002; 6: 53 ± 55)
Keywords leucoencephalopathy stigma of mental illness
INTRODUCTION
P
rogressive spongiform leucoencepha lopathy is a rare complication of inhaling heroin vapour in the manner described as `chasing the dragon’. The powdered heroin is placed on tinfoil, which is heated from below with a flame. As the heroin heats and becomes liquid, a pyrolysat e vapour is released which is inhaled through a straw. Leucoenceph alopathy attributed to this form of heroin inhalation was first reported from the Netherlands, where it occurred as a cluster affecting 47 heroin users. 1 These patients presented with apathy, bradyphrenia, motor restlessnes s and cerebellar ataxia. They then passed through a stage of worsening cerebella r symptoms and gait disturbance . Eleven patients died and the remainder showed partial recovery. Subsequent smaller outbreaks have occurred in Europe, and the first three American cases were recently reported.2 These patients had classical MRI findings, demonstrating diffuse cerebral and cerebellar white matter hyperintensitie s with a distribution similar to the hypodensitie s apparent on CT scanning of the index cases. They were treated with the antioxidant, coenzyme Q, and experienced clinical improvement . The causative toxin has not been established, but is thought to be a toxic contaminant of the heated pyrolysate, as the condition has not been reported in other forms of heroin use, with the exception of a child who swallowed heroin.3
heroin misuse
CASE REPORT A 47-year-old woman, under the care of psychiatrist s for amphetamine misuse, depression and persecutory ideas, was brought to the psychiatric clinic by relatives who said she was drowsy and confused. Ten days before presentation she was seen in the Drug Clinic, where she stated that she was no longer taking amphetamines but had been `smoking’ heroin for four weeks in order to `lift her spirits’. She was described as being paranoid, panicky and depressed. She was prescribed chlorpromazi ne 50 mg tds, doxepin 25 mg od, and diazepam 5 mg tds. Although she had used excessive alcohol previously , she denied recent alcohol intake and said she had never injected drugs. She was referred to the admitting medical team for investiga tion of her confusion. On examination she was found to be afebrile. She was disoriented regarding time and place, appearing agitated and restless. She made frequent non-purpose ful movements, her gait was unsteady and she spoke slowly, with a garbled speech content. She was otherwise considered to be neurological ly intact. The full blood count, ESR and Creactive protein were normal. Renal, liver and bone profiles , TSH, blood sugar and clotting screen were normal. CT brain scans before and after contrast medium were reported as essentially normal. She was therefore transferred to a psychiatric ward, where she became increasingl y ataxic and incontinent .
54
GM Sayers et al
On medical review she was unable to answer most questions. All movements and speech were slow. She had increased tone in both arms and legs and cogwheel rigidity. Power, sensation and reflexes were normal. She was unable to walk, predominantly due to truncal ataxia. An MRI brain scan showed diffuse high-intensi ty signals affecting both cerebral hemisphere s. Review of the CT scan revealed hypodensitie s in a correspondin g distribution. Cerebrospinal fluid contained 51 wbc/mm 3 , 185 rbc/mm3 and no organisms . The CSF glucose was 3.9 mmol/L, lactate was 1.3 mmol/L and protein was 0.92 g/L. Blood and urine cultures were sterile. Copper studies, serum electrophoresis, B12, auto-antibodies , VDRL, TPHA, hepatitis-C serology , and HIV antigen and antibody tests were normal. A diagnosis was made of heroin pyrolysat e syndrome with parkinsonis m and global cognitive impairment . She was treated with coenzyme Q 30 mg tds, and although she became independently mobile and continent she remained cognitivel y impaired.
DISCUSSION A study of heroin chasers showed that, although chasing is more costly than injecting, it tends to be favoured by younger heroin users. Many were actively avoiding intravenous use of the drug, despite having the opportunity to do so. 4 Although the risk to injectors of infections like HIV and hepatitis B remains significant , a further risk emerged last year, with 35 deaths resulting from Clostridium novyi type A septicaemia in injecting drug users in the UK. These deaths were attributed to a contaminated batch of heroin.5 A circular from the Department of Health has warned that this heroin may be retrieved and released back onto the market. Consequentl y, the advice given to injecting drug users is to smoke heroin instead of injecting it.6 The word `smoke’ in this context may be ambiguous, and our patient described herself as `smoking’ heroin, with the history of `chasing’ only emerging much later from her relatives. Should chasing become the preferre d mode of heroin usage, awareness of the heroin pyrolysat e syndrome by both professiona ls and users becomes important. A further issue arising is how a diagnosis of mental illness may delay or prevent the diagnosis of organic illness. High rates of physica l illness go undetected in psychiatric patients, partly due to the fact that the stigma of mental
illness may impair their care.7 Among the causes of excess mortality in patients with schizophren ia are failed recognition of medical disease and missed medical diagnosis.8 It has been said that ``referra l to a psychiatris t should not be made just because an organic disease has not been establishe d or because the diagnosis is uncertain’’ .9 Goffman, 1 0 in describing stigma, suggests that ``an individua l who might have been received easily in ordinary social intercourse possesses a trait that can obtrude itself upon attention and turn those of us who he meets away from him, breaking the claim that his other attributes have on us’’. In our case, the patient’s psychiatric history seemed to have blinded us to physical signs which clearly differed from those which would accord with the psychiatric diagnoses. Among the differentia l diagnoses entertained by consultants from three different medical discipline s were ``drug intoxication’’ , ``catatonic psychosis with rigidity due to chlorpromazi ne side-effects’ ’, and a ``conversio n disorder with depression’’ . It only became apparent following the MRI scan that organic illness was causative. Stigmatization of mental illness is centuries old and attempts have been made to alter this perception. An alternative view is that, by concentrating on the term `stigma’, we render the act of unfair treatment invisible, and disregard the way in which mentally ill people experience discriminat ion. From this perspective ``the mark of shame should reside not with the service user, but those who behave unjustly towards her or him.’’1 1
ACKNOWLEDGEMENTS We thank Dr Peter Rudge who made the diagnosis, reviewed the neuroradiolo gy and commented on the draft.
KEY POINTS . Heroin pyrolysat e syndrome is a rare complication of heroin misuse . It may become more common because of fears relating to heroin injection . Organic disorders can be wrongly attributed to pre-existing mental illness, particularly if the diagnosis is obscure
REFERENCES 1. Wolters EC, van Wijngaarden GK, Stam FC et al (1982) Leucoencephalopathy after inhaling ``heroin’’ pyrolysate. Lancet ii: 1233 ± 37. 2. Kriegstein AR, Shungu DC, Millar WS et al (1999) Leukoencephalopathy and raised brain lactate from heroin vapour inhalation (``chasing the dragon’’). Neurology 53: 1765 ± 73.
3. Roulet-Perez E, Maeder P, Rivier L et al (1992) Toxic leucoencephalopathy after heroin ingestion in a 2-year-old child. Lancet 340: 729. 4. Gossop M, Griffiths P, Strang J (1988) Chasing the dragon: characteristics of heroin chasers. Br J Addiction 83: 1159 ± 62.
Heroin-induced leucoencephalopathy
5. Christie B (2000) Gangrene bug ``killed 35 heroin users’’. Br Med J 320: 1690 ± 91. 6. UK Department of Health Message, Reference: CEM/CMO/ 2001/8. Further information can be found at [email protected] 7. Phelan M, Stradins L, Morrison S (2001) Physical health of people with severe mental illness. Br Med J 322: 443 ± 44. 8. Brown S, Inskip H, Barraclough B (2000) Causes of the excess mortality of schizophrenia. Br J Psychiatry 177: 212 ± 17.
55
9. Bridges KW, Goldberg DP (1984) Psychiatric illness in inpatients with neurological disorders: patients’ views on discussion of emotional problems with neurologists. Br Med J 289: 656 ± 58. 10. Goffman E (1979) Stigma: Notes on the Management of Spoiled Identity, p 15. Penguin Books Ltd, Harmondsworth, Middlesex, England. 11. Sayce L (1998) Stigma, discrimination and social exclusion: What’s in a word? J Mental Health 7: 331 ± 34.
2002 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 2002 Volume 6 Pages 53 ± 55
53
Heroin-induced leucoencephalopathy misdiagnosed as psychiatric illness GWEN M SAYERS, MARY C GREEN AND RICHARD E SHAFFER Northwick Park Hospital, Middlesex, UK
Correspondence Address Gwen M Sayers, BSc MB BCh FRCP, Consultant Physician and Honorary Clinical Senior Lecturer (Imperial College School of Medicine), Northwick Park Hospital, Watford Road, Midddlesex HA1 3UJ Tel: 0208 869 2579 Fax: 0208 8692241
Received 26 September 2001; revised 20 November 2001; accepted for publication 22 November 2001
We present a patient with a background of psychiatric illness who was admitted to hospital with neurological symptoms and signs. Although the organic cause of the neurological disorder was extremely uncommon and hence not readily diagnosed, the signs clearly did not accord with the preexisting psychiatric diagnoses. Nevertheless, several clinicians attributed the cause of the disorder to mental illness, or drug side-effects. It is possible that patients suffering from mental illness may be assessed differently, perhaps due to prejudgemen t by clinicians. (Int J Psych Clin Pract 2002; 6: 53 ± 55)
Keywords leucoencephalopathy stigma of mental illness
INTRODUCTION
P
rogressive spongiform leucoencepha lopathy is a rare complication of inhaling heroin vapour in the manner described as `chasing the dragon’. The powdered heroin is placed on tinfoil, which is heated from below with a flame. As the heroin heats and becomes liquid, a pyrolysat e vapour is released which is inhaled through a straw. Leucoenceph alopathy attributed to this form of heroin inhalation was first reported from the Netherlands, where it occurred as a cluster affecting 47 heroin users. 1 These patients presented with apathy, bradyphrenia, motor restlessnes s and cerebellar ataxia. They then passed through a stage of worsening cerebella r symptoms and gait disturbance . Eleven patients died and the remainder showed partial recovery. Subsequent smaller outbreaks have occurred in Europe, and the first three American cases were recently reported.2 These patients had classical MRI findings, demonstrating diffuse cerebral and cerebellar white matter hyperintensitie s with a distribution similar to the hypodensitie s apparent on CT scanning of the index cases. They were treated with the antioxidant, coenzyme Q, and experienced clinical improvement . The causative toxin has not been established, but is thought to be a toxic contaminant of the heated pyrolysate, as the condition has not been reported in other forms of heroin use, with the exception of a child who swallowed heroin.3
heroin misuse
CASE REPORT A 47-year-old woman, under the care of psychiatrist s for amphetamine misuse, depression and persecutory ideas, was brought to the psychiatric clinic by relatives who said she was drowsy and confused. Ten days before presentation she was seen in the Drug Clinic, where she stated that she was no longer taking amphetamines but had been `smoking’ heroin for four weeks in order to `lift her spirits’. She was described as being paranoid, panicky and depressed. She was prescribed chlorpromazi ne 50 mg tds, doxepin 25 mg od, and diazepam 5 mg tds. Although she had used excessive alcohol previously , she denied recent alcohol intake and said she had never injected drugs. She was referred to the admitting medical team for investiga tion of her confusion. On examination she was found to be afebrile. She was disoriented regarding time and place, appearing agitated and restless. She made frequent non-purpose ful movements, her gait was unsteady and she spoke slowly, with a garbled speech content. She was otherwise considered to be neurological ly intact. The full blood count, ESR and Creactive protein were normal. Renal, liver and bone profiles , TSH, blood sugar and clotting screen were normal. CT brain scans before and after contrast medium were reported as essentially normal. She was therefore transferred to a psychiatric ward, where she became increasingl y ataxic and incontinent .
54
GM Sayers et al
On medical review she was unable to answer most questions. All movements and speech were slow. She had increased tone in both arms and legs and cogwheel rigidity. Power, sensation and reflexes were normal. She was unable to walk, predominantly due to truncal ataxia. An MRI brain scan showed diffuse high-intensi ty signals affecting both cerebral hemisphere s. Review of the CT scan revealed hypodensitie s in a correspondin g distribution. Cerebrospinal fluid contained 51 wbc/mm 3 , 185 rbc/mm3 and no organisms . The CSF glucose was 3.9 mmol/L, lactate was 1.3 mmol/L and protein was 0.92 g/L. Blood and urine cultures were sterile. Copper studies, serum electrophoresis, B12, auto-antibodies , VDRL, TPHA, hepatitis-C serology , and HIV antigen and antibody tests were normal. A diagnosis was made of heroin pyrolysat e syndrome with parkinsonis m and global cognitive impairment . She was treated with coenzyme Q 30 mg tds, and although she became independently mobile and continent she remained cognitivel y impaired.
DISCUSSION A study of heroin chasers showed that, although chasing is more costly than injecting, it tends to be favoured by younger heroin users. Many were actively avoiding intravenous use of the drug, despite having the opportunity to do so. 4 Although the risk to injectors of infections like HIV and hepatitis B remains significant , a further risk emerged last year, with 35 deaths resulting from Clostridium novyi type A septicaemia in injecting drug users in the UK. These deaths were attributed to a contaminated batch of heroin.5 A circular from the Department of Health has warned that this heroin may be retrieved and released back onto the market. Consequentl y, the advice given to injecting drug users is to smoke heroin instead of injecting it.6 The word `smoke’ in this context may be ambiguous, and our patient described herself as `smoking’ heroin, with the history of `chasing’ only emerging much later from her relatives. Should chasing become the preferre d mode of heroin usage, awareness of the heroin pyrolysat e syndrome by both professiona ls and users becomes important. A further issue arising is how a diagnosis of mental illness may delay or prevent the diagnosis of organic illness. High rates of physica l illness go undetected in psychiatric patients, partly due to the fact that the stigma of mental
illness may impair their care.7 Among the causes of excess mortality in patients with schizophren ia are failed recognition of medical disease and missed medical diagnosis.8 It has been said that ``referra l to a psychiatris t should not be made just because an organic disease has not been establishe d or because the diagnosis is uncertain’’ .9 Goffman, 1 0 in describing stigma, suggests that ``an individua l who might have been received easily in ordinary social intercourse possesses a trait that can obtrude itself upon attention and turn those of us who he meets away from him, breaking the claim that his other attributes have on us’’. In our case, the patient’s psychiatric history seemed to have blinded us to physical signs which clearly differed from those which would accord with the psychiatric diagnoses. Among the differentia l diagnoses entertained by consultants from three different medical discipline s were ``drug intoxication’’ , ``catatonic psychosis with rigidity due to chlorpromazi ne side-effects’ ’, and a ``conversio n disorder with depression’’ . It only became apparent following the MRI scan that organic illness was causative. Stigmatization of mental illness is centuries old and attempts have been made to alter this perception. An alternative view is that, by concentrating on the term `stigma’, we render the act of unfair treatment invisible, and disregard the way in which mentally ill people experience discriminat ion. From this perspective ``the mark of shame should reside not with the service user, but those who behave unjustly towards her or him.’’1 1
ACKNOWLEDGEMENTS We thank Dr Peter Rudge who made the diagnosis, reviewed the neuroradiolo gy and commented on the draft.
KEY POINTS . Heroin pyrolysat e syndrome is a rare complication of heroin misuse . It may become more common because of fears relating to heroin injection . Organic disorders can be wrongly attributed to pre-existing mental illness, particularly if the diagnosis is obscure
REFERENCES 1. Wolters EC, van Wijngaarden GK, Stam FC et al (1982) Leucoencephalopathy after inhaling ``heroin’’ pyrolysate. Lancet ii: 1233 ± 37. 2. Kriegstein AR, Shungu DC, Millar WS et al (1999) Leukoencephalopathy and raised brain lactate from heroin vapour inhalation (``chasing the dragon’’). Neurology 53: 1765 ± 73.
3. Roulet-Perez E, Maeder P, Rivier L et al (1992) Toxic leucoencephalopathy after heroin ingestion in a 2-year-old child. Lancet 340: 729. 4. Gossop M, Griffiths P, Strang J (1988) Chasing the dragon: characteristics of heroin chasers. Br J Addiction 83: 1159 ± 62.
Heroin-induced leucoencephalopathy
5. Christie B (2000) Gangrene bug ``killed 35 heroin users’’. Br Med J 320: 1690 ± 91. 6. UK Department of Health Message, Reference: CEM/CMO/ 2001/8. Further information can be found at [email protected] 7. Phelan M, Stradins L, Morrison S (2001) Physical health of people with severe mental illness. Br Med J 322: 443 ± 44. 8. Brown S, Inskip H, Barraclough B (2000) Causes of the excess mortality of schizophrenia. Br J Psychiatry 177: 212 ± 17.
55
9. Bridges KW, Goldberg DP (1984) Psychiatric illness in inpatients with neurological disorders: patients’ views on discussion of emotional problems with neurologists. Br Med J 289: 656 ± 58. 10. Goffman E (1979) Stigma: Notes on the Management of Spoiled Identity, p 15. Penguin Books Ltd, Harmondsworth, Middlesex, England. 11. Sayce L (1998) Stigma, discrimination and social exclusion: What’s in a word? J Mental Health 7: 331 ± 34.
