US case highlights dangers of fentanyl inhalation

Earlier this year, a 47-year-old healthy man, with no known medical history, arrived unconscious — by ambulance — to an emergency department in Oregon, the US.

As clinicians began administering life-saving treatment, they searched for the cause — reporting a surprising and unprecedented diagnosis: toxic leukoencephalopathy by fentanyl inhalation.

In other words, the patient had inhaled fentanyl causing large sections of white matter in the brain to become inflamed to the point where he had lost consciousness and risked irreversible loss of brain function, or possibly death.

While previous cases caused by inhaling heroin have been documented, the patient at the Oregon Health & Science University (OHSU) emergency department is thought to be the "first documented case involving inhalation of illicit fentanyl".

A non-standard test

The lead author of the study said it should be taken as a warning about the danger of a substance that is cheap, readily available and 50 times more potent than heroin.

"Opioid use, especially fentanyl, has become very stigmatised," said lead author Chris Eden, MD, now a second-year resident in internal medicine in the OHSU School of Medicine who was part of the patient's treatment team.

"This is a case of a middle-class man, in his late 40s, with kids, who used fentanyl for the first time. It demonstrates that fentanyl can affect everyone in our society."

Although this is the first documented case, Eden said it's likely other cases simply weren't recognised due in part to the fact that relatively little is known about the syndrome's physiology. In addition, he said hospitals haven't traditionally included fentanyl in their standard urinalysis drug screens.

At the same time, fatal and nonfatal overdoses due to fentanyl and other opioids are all too common.

"We know very well the classic opiate side effects: respiratory depression, loss of consciousness, disorientation," Eden noted. "But we don't classically think of it causing possibly irreversible brain damage and affecting the brain, as it did in this case."

Magnetic resonance imaging revealed inflammation in the brain. However, the patient's lingering loss of consciousness, memory and function could have been due to any number of causes — stroke, carbon monoxide exposure or metabolic disease among them. 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 help regain his speech and function. He is now home with his family in the Seattle area and back to work. To this day, he has no memory of the episode.

The successful outcome involved wraparound treatment with numerous clinicians and support at Oregon's academic health centre and single largest hospital, all operating with a patient-centred approach.

"This case involved internal medicine, neurology, neuroradiology and palliative care physicians, in addition to nurses, social workers, discharge planners, physical therapists, dieticians and pharmacists," Eden said.

The related publication in BMJ Case Reports also includes a perspective from the patient. "I have regrets often about what I did to myself, my wife and my family," he said. "I'm grateful to all the doctors, nurses and EMTs who saved my life, and the therapists who got me back to a functioning member of society."

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 of OHSU and now with Penn Medicine.

This case can help inform future clinicians to be watchful for other toxins that may not be initially identified on screening tests, according to the researchers. "Furthermore, this case illustrates the need for inclusion of fentanyl in routine urine drug screens for earlier identification and appropriate management."

Image credit: OHSU.