SHM Converge Scientific Abstract ePoster Gallery-A Fatal Case of Fentanyl Induced Leukoencephalopathy

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This document describes a fatal case of fentanyl-induced toxic leukoencephalopathy (TLE) in a 46-year-old woman with ESRD on hemodialysis, chronic HFrEF, COPD on home oxygen, chronic DVT on apixaban, hepatitis C, and polysubstance use with known IV drug use. She presented with a week of progressive headache followed by rapidly worsening confusion, ultimately requiring intubation for airway protection.<br /><br />Initial evaluation showed leukocytosis and elevated inflammatory markers. Head CT was initially negative, but within 12 hours imaging suggested evolving cerebral edema and reduced intracranial arterial circulation. Because she was anticoagulated, lumbar puncture was not performed. She was empirically treated for possible meningitis/encephalitis with antibiotics and acyclovir and received hypertonic saline for cerebral edema.<br /><br />MRI on day 3 demonstrated diffuse global cerebral and cerebellar diffusion restriction without enhancement, making infection less likely and raising concern for opiate-related brain injury. EEG on day 5 ruled out nonconvulsive status epilepticus. Her condition continued to worsen with hemodynamic instability requiring vasopressors. Follow-up CT on day 6 showed catastrophic cerebral edema with complete effacement of sulci and ventricles and transtentorial herniation. A nuclear brain perfusion scan showed absent cerebral blood flow, and brain death was declared.<br /><br />The report emphasizes that opiate-induced toxic leukoencephalopathy is a rare but life-threatening complication of fentanyl and other opioid use, often presenting with confusion, stupor, coma, and diffuse white matter injury. It highlights the need for a high index of suspicion in patients with unexplained acute encephalopathy, especially amid the fentanyl overdose crisis, and argues for including fentanyl in routine urine drug screening to improve early diagnosis and outcomes.

Asset Subtitle

Fatima Elwalid

Meta Tag

Author List Fatima Elwalid, Maninderjit Singh, Sobia Syed, Syed R. Shah

Category Clinical Vignettes

Concept Toxic Leukoencephalopathy

Concept Fentanyl

Concept Encephalopathy

Concept Supportive Care

Concept Airway Protection

Distinguished Non-Finalist

Presenter Organization NW Family Medicine Residency

Presenting Author Fatima Elwalid

Track Adult

Keywords

fentanyl

toxic leukoencephalopathy

opioid overdose

brain edema

diffusion restriction

brain death

encephalopathy

hemodialysis

intravenous drug use

cerebral herniation

Toxic Leukoencephalopathy

Fentanyl

Encephalopathy

Supportive Care

Airway Protection