Title : From humor to harm: A case of cocaine-induced toxic leukoencephalopathy mimicking delirium
Abstract:
Introduction: Toxic Leukoencephalopathy (TL) is cerebral white matter damage caused by toxic agents. It affects higher cerebral function resulting in forgetfulness, inattention, changes in personality, dementia, coma, and even death, and is detectable on MRI. Preservation of language, typical in TL, can mask other neurobehavioral deficits. It is necessary to rule out delirium and psychiatric diseases which can also present with a similar picture. Here, we report a case of cocaine-induced TL in a patient with chronic Ssubstance Use Disorder (SUD), despite a normal MRI 3 months prior.
Case Presentation: A 47-year-old male with SUD was admitted due to subacute confusion and abnormal behavior following recent binge cocaine use. After returning from a binge 1 month ago, he experienced a week-long illness with fever, cough, and fatigue, followed by progressive decline, including confusion, memory loss, impaired balance, and bizarre behaviors. Examination revealed odd affect, and a wide-based gait. An MRI three months prior was unremarkable. The following night, he exhibited agitation with possession of a knife and gross disorientation, prompting a mental health emergency response code. His symptoms initially appeared waxing and waning, mimicking delirium. The patient was safely redirected and remained at the hospital voluntarily. Throughout his hospital admission, the patient used humor to mask his cognitive deficits. Delirium workup was initiated and a repeat MRI was ordered given progressive cognitive decline, and showed extensive subcortical white matter damage consistent with toxic leukoencephalopathy.
Discussion/Conclusion: The case underscores the diagnostic challenges of cocaine-induced TL due to its varied neurological manifestations. It might mimic delirium and present with pseudo “waxing and waning”. In the case of our patient, he used humor to mask his inability to answer questions about his family, and appeared funny rather than clueless. Despite a normal MRI three months prior, the patient showed signs of subacute confusion and progressive worsening cognitive decline, suggesting TL rather than delirium. Clinical suspicion, aided by neuroimaging, is crucial for accurate diagnosis in patients with substance abuse and neurobehavioral deficits. Treatment approaches for cocaine-induced TL lack consensus, with outcomes ranging from reversible to permanent damage whether delirium is often reversible with the treatment of the underlying cause. In this case, vitamin therapy (E, A, C, coQ10) and neurocognitive rehabilitation were initiated, highlighting comprehensive care. Continued monitoring and interdisciplinary collaboration are vital due to uncertainty regarding TL's reversibility.
Audience Take Away Notes:
- The audience will learn about the diagnostic challenges of cocaine-induced TL, which can resemble other phenomena such as delirium. They will understand the importance of considering substance use as a potential cause of cognitive decline, even in the absence of abnormalities on recent imaging
- For healthcare professionals, this information will aid in developing a heightened awareness and clinical suspicion for TL in patients with a history of substance use disorder (SUD). It emphasizes the need for comprehensive neuroimaging and interdisciplinary collaboration in managing such cases
- Yes, this case study can serve as a valuable addition for other faculty members in various fields including neurology, psychiatry, radiology, and addiction medicine. It can be used to expand research on the neurological impacts of substance abuse, the nuances of TL, and the challenges of differential diagnosis
