Earlier this year, a 47-year-old healthy man with no known medical history arrived unconscious by ambulance at an emergency room in Oregon, USA.
As doctors began administering life-saving treatment, they searched for the cause and reported a surprising and unprecedented diagnosis: toxic leukoencephalopathy from fentanyl inhalation.
In other words, the patient had inhaled fentanyl, causing large portions of the white matter in the brain to become so inflamed that he lost consciousness and risked irreversible loss of brain function or possibly death.
While previous cases involving heroin inhalation have been documented, the patient in the emergency room at Oregon Health & Science University (OHSU) is believed to be the “first documented case involving illicit inhalation Fentanyl went.”
A non-standard test
The study’s lead author said the study should be seen as a warning about the danger of a substance that is cheap, readily available and 50 times more potent than heroin.
“There is a lot of stigma around opioid use, particularly fentanyl,” said lead author Chris Eden, MD, now a second-year internal medicine resident at the OHSU School of Medicine and part of the patient’s treatment team.
“This is the case of a middle-class man, in his late 40s, with children, who took fentanyl for the first time. It shows that fentanyl can affect everyone in our society.”
Although this is the first documented case, Eden said other cases likely simply went unrecognized, in part due to the fact that relatively little is known about the syndrome’s physiology. Additionally, he said hospitals have traditionally not included fentanyl in their standard urine drug screens.
At the same time, fatal and non-fatal overdoses from fentanyl and other opioids are all too common.
“We know very well the classic side effects of opiates: respiratory depression, unconsciousness, disorientation,” Eden noted. “But we do not classically assume that it may cause irreversible brain damage and affect the brain, as was the case in this case.”
Magnetic resonance imaging showed inflammation in the brain. However, the patient’s ongoing loss of consciousness, memory and function could be due to a number of causes – including stroke, carbon monoxide exposure or metabolic disease. Ultimately, a non-standard drug test revealed the presence of fentanyl in his system.
Slow recovery
Fortunately for the patient, he slowly recovered after 26 days in the hospital, followed by a stay in a skilled nursing facility to regain his speech and function. He is now home with his family in the Seattle area and back at work. To this day he has no memory of the episode.
The successful outcome included comprehensive care with multiple physicians and support at the academic health center and Oregon’s largest hospital, all working with a patient-centered approach.
“In addition to nurses, social workers, discharge planners, physical therapists, nutritionists and pharmacists, internal medicine, neurology, neuroradiology and palliative care physicians were involved in this case,” Eden said.
The corresponding publication in BMJ case reports also includes a patient perspective. “I often regret what I did to myself, my wife and my family,” he said. “I am grateful to all the doctors, nurses and paramedics who saved my life and to the therapists who made me a functioning member of society again.”
In addition to Eden, co-authors include Duna Alkhalaileh, DO, MPH, David Pettersson, MD, and Alan Hunter MD, of OHSU; and Asad Arastu, MD, previously at OHSU and now at Penn Medicine.
This case may help future doctors pay attention to other toxins that may not initially be identified in screening tests, the researchers said. “Furthermore, this case highlights the need to include fentanyl in routine urine drug testing to allow for earlier identification and appropriate treatment.”