Subacute onset of oculogyric crises and generalized dystonia following intranasal administration of heroin

A case is I reported of a patient who experienced sudden onset of severe re spiratory failure, shock and coma after first-time intranasal heroin abuse. During the following days full consciousness was restored, revealing persi stent oculogyric crises, axial,retropulsive dystonia and ataxia. Initially computer tomography (CT) scans of the brain were normal and cerebral spinal fluid examination showed a slight elevation of lactate. Magnetic resonance imaging (MRI) scans of the brain demonstrated diffuse bilateral subconical white matter hyperintensities, with sparing of the U-fibres, symmetric bil ateral hyperintensities of the globus pallidum and very hyperintensive subc ortical foci in the right hemisphere. Differential diagnostic assessment, t reatment, clinical and MRI course of a 6-month follow-up are discussed.