Heroin-associated spongiform leukoencephalopathy
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A 29-year-old man presented with a three-week history of slurred speech, poor coordination, and imbalance while walking. He did not have a family history of neurodegenerative disorders or autoimmune conditions. On physical exam, he was alert and oriented to person, place, time, and situation. He displayed dysarthric speech and ataxic gait, and he scored 4/5 in upper and lower extremity strength testing. Cerebrospinal fluid studies revealed normal protein, cell count, and glucose levels. Syphilis, HIV, West Nile, HSV, JC virus, CMV, and arbovirus serologies returned negative. Likewise, the patient tested negative for ANA and rheumatoid factor antibodies. Urine toxicology was positive for opiates. Upon further questioning, the patient admitted to smoking heroin vapor. Over six days of hospitalization, his physical exam findings were stable, and the patient was discharged to a rehabilitation facility.

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