# Positive 14-3-3 protein in cerebrospinal fluid followed by poppy-induced delayed post-hypoxic leukoencephalopathy: A case report

## TL;DR

A 70-year-old woman developed a rare brain condition after a poppy overdose, with a unique protein in her spinal fluid offering potential diagnostic value.

## Contribution

First documented case of DPHL with positive 14-3-3 protein in cerebrospinal fluid following poppy overdose.

## Key findings

- DPHL presented with choreoathetosis and dementia after a lucid interval following poppy overdose.
- 14-3-3 protein was detected in cerebrospinal fluid, suggesting potential as a biomarker for DPHL.
- MRI showed characteristic bilateral hyperintense signals in brain regions consistent with DPHL.

## Abstract

Delayed post-hypoxic leukoencephalopathy (DPHL) is characterized by a biphasic clinical course, with complete recovery from coma to a fully conscious state lasting one to four weeks (lucid interval), followed by abrupt neurological deterioration as an indirect consequence of hypoxic events like carbon monoxide poisoning and narcotic drug overdose. To our best knowledge, there are no documented cases in literature of choreoathetosis and dementia following poppy-induced DPHL with 14-3-3 protein in cerebrospinal fluid (CSF).

We report the case of a 70-year-old female who underwent cardiopulmonary resuscitation (CPR) due to overdose of homemade refined opium poppy paste two weeks prior to presentation. She presented a progressive cognitive decline, along with the development of apraxia and choreic movement affecting her tongue and bilateral upper and lower extremities. During the symptomatic phase, brain magnetic resonance imaging (MRI) showed bilateral symmetrical hyperintense signals mostly in central frontal, temporal, and parieto-occipital lobes in the diffusion weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) sequences which are the characteristic findings of DPHL. CSF routine analysis, as well as toxicology screening, autoimmune and paraneoplastic encephalitis panels were negative, but the presence of 14-3-3 protein in the CSF was detected. With steroid therapy, hyperbaric oxygen therapy and symptomatic treatment, she experienced gradual improvement in cognition, motivation, and psychomotor function.

DPHL represents a distinct form of encephalopathy characterized by unique clinical course and imaging features. It is the first report of DPHL with positive 14-3-3 protein in CSF. The potential of 14-3-3 protein as a biomarker for diagnosing DPHL and its ability to predict disease severity and prognosis warrants further research.