Delayed Post-Hypoxic Leukoencephalopathy Presenting with Catatonia Symptoms Sequelae of Opioid Overdose and Trauma

Delayed post-hypoxic leukoencephalopathy (DPHL) is a rare complication of hypoxic brain injury. It can present with a wide spectrum of symptoms 1-4 weeks after the incident. The diagnosis is supported by the white matter changes on the magnetic resonance imaging (MRI). We present a 54-year-old Caucasian female with a 3-week history of opioid overdose, and sexual trauma presented to the hospital for showing symptoms including unresponsiveness, irritability, mobility issues, aggressive and combative behavior for three days. Substance abuse and infections were ruled out. Head computed tomography (CT) showed no acute findings. MRI of the brain without contrast & and T2-weighted fluid-attenuated inversion recovery (T2-FLAIR) without contrast showed extensive signal abnormalities throughout the white matter of bilateral cerebral hemispheres which was suggestive of hypoxic brain injury. The onset of catatonia-like symptoms after three weeks and imaging findings supported the diagnosis of DPHL. The patient showed improvement after starting physical therapy and restarting home dose clonazepam. There are no standardized diagnostic criteria for DPHL, which makes it challenging for clinicians to diagnose. It is important to keep DPHL in differential diagnosis especially when there is history of recent hypoxic injury for optimal patient care.