Acute parkinsonism with corresponding lesions in the basal ganglia after heroin abuse

Parkinsonian syndromes with encephalopathy after heroin abuse are rare. We report a 41-year-old Caucasian woman presenting with symmetric akinetic-rigidic parkinsonism. Twenty-four hours after snorting heroin, the patient exhibited a generalized dyskinetic syndrome and impaired vision, and severe parkinsonian symptoms developed within 2 weeks. The akinetic-rigid syndrome showed good response to levodopa therapy with motor fluctuations over the course of treatment. Previous studies on heroin-induced parkinsonism have reported leukoencephalopathy with diffuse white matter hyperintensities on brain MRI corresponding to spongiform degeneration.^1,2 However, gray matter lesions of the basal ganglia and, to a lesser extent, the cerebral cortex, due to heroin abuse have not been reported before in drug-induced parkinsonism (figure, A–C). We speculate that the affected brain regions reflect a noxious effect of heroin or used additives on metabolical active neurons.

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Figure. The fluid-attenuated inversion recovery image (A) shows bilateral hyperintensities in the basal ganglia and the occipitopolar cortex. The latter and the globus pallidus internus are also hyperintense on the T1-weighted image (B), indicating hemorrhagic transformation. The T2-weighted image of the mesencephalon (C) shows hyperintense substantia nigra similar to the basal ganglia.

1. Wolters EC, van Wijngaarden GK, Stam FC, et al. Leucoencephalopathy after inhaling “heroin” pyrolysate. Lancet 1982;2:1233–1237.

2. Kriegstein AR, Shungu DC, Millar WS, et al. Leukoencephalopathy and raised brain lactate from heroin vapor inhalation (“chasing the dragon”). Neurology 1999;53:1765–1773.OpenUrlAbstract/FREE Full Text