tube placement given she was unable to eat , which was placed on day three of hospitalization . She regained her decision-making capacity and discharged herself against medical advice the following day , the fourth day from admission . The patient has since been lost to follow-up and refused to restart buprenorphine under in-patient psychiatry direction .
DISCUSSION
TL began to be formally studied in the 1980s beginning with cases of toluene abuse linked to white matter changes on brain MRIsW . 2 By the 2000s , with improvement in MRI technology , TL from substances of abuse , though more commonly identified than other causes such as radiation and environmental toxins , still appears rare throughout the literature . 2 – 4 The number of reported cases are on order of magnitude in the hundreds . 2 , 5 – 7 TL has occurred with overdoses of heroin , cocaine and methadone ; however , there were only two documented cases of buprenorphine induced leukoencephalopathy . These cases include a pediatric ingestion and an adult injection of buprenorphine both causing leukencephalopathy . 6 , 8 – 10 Neither of those cases exhibited symptoms of catatonia . 6 , 10
TL is caused by white matter changes in the brain , primarily diagnosed radiologically after clinical suspicion is raised . 2 It can be caused by chemoradiation , medications , or drug abuse , among other causes . 4 , 11 The patterns of findings on imaging are typically consistent across each cause . 2 – 4 Brain MRIs in cases of TL due to opioids typically show features that involve cerebellar and posterior cerebellar hemispheres , which include the internal capsule posterior , and can include the hippocampus , basal ganglia , thalamus , and corpus callosum .
12 – 14
This pattern is seen in the two cases cited in the literature with buprenorphine induced TL . The pediatric ingestion case included MRI findings significant for posterior cortical white matter changes and cytotoxic edema on diffusion tensor imaging , and the adult case included MRI findings of diffuse leukoencephalopathy within the periventricular , deep and subcortical white matter of the frontal and parietal lobes . 6 , 10 These findings are consistent with MRI interpretation of images performed in this case .
FIGURE 1
Magnetic resonance imaging in T2-weighted fluid-attenuated inversion recovery ( A ) and diffusion-tensor imaging with apparent diffusion coefficient axial view ( B ) show changes in the splenium of corpus callosum associated with toxic spongiform leukoencephalopathy .
Patients with TL can demonstrate a range of symptoms depending on the insulting agent , part of the brain that experiences the most damage , and stage of progression . 4 , 11 TL from heroin , for example , is characterized in three stages . 4 The first stage is typically a cerebellar stage with features such as limb ataxia , apathy , and akathisia . 4 Stage two usually features worsening ataxia , choreoathetoid movement , and myoclonus . 4 The last stage features hyperpyrexia , akinetic mutism , and stretching spasms , which can mimic decerebrate-like posturing . 4 This patient ’ s clinical features were more congruent with catatonia or a catatonic-like state than those described above .
Catatonia is a psychomotor condition characterized and diagnosed with at least three of the following : stupor , catalepsy , waxy flexibility , mutism , negativism , posturing , mannerisms , stereotypy , agitation , or excessive motor activity that is purposeless , grimacing , echolalia , or echopraxia . 8 , 15 Toxic , metabolic , psychiatric , and infectious processes are etiologically responsible , and the pathophysiology appears to involve decreased γ-aminobutyric acid type A and dopamine receptor type D2 activity and increased N-methyl-D-aspartic acid receptor activity between the basal ganglia , cortex , and thalamus . 8 , 16 Catatonia is associated with many psychiatric conditions , including schizophrenia or mania . 17 , 18 Catatonia is a clinical diagnosis , though it can be challenging to diagnose . 1 , 19 The severity of catatonia can range in features from mild to severe and can even cause death . 20 At the severe end of the range , malignant catatonia features high fevers and autonomic instability , which can be life threatening .
17 , 18 , 20
Therefore , recognizing and treating catatonia is crucial .
Tools like the Bush Francis Scale are also used to support a diagnosis of catatonia and grade symptom severity . 1 , 19 We performed a post-hoc Bush Francis Scale for catatonia based only on documented findings in the EMR within one day of the patient ’ s admission . We used our documented objective exams as the primary team caring for the patient in conjunction with assessments documented by psychiatry and neurology to complete the scale . If the finding was not described in the chart , the answer was considered absent . This score may underestimate her symptoms given it was not performed in real time ; however , it can be used to support the diagnosis of catatonia . Her total score was 23 points out of a maximum of 42 points , which strongly support
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