Patient was a young adult working in finance at a major tech company found to be mute and diaphoretic.

Physical exam notable for fever, tachycardiac, hypertension, awake but not following commands, aphasic, and with hyperreflexia and muscle ridigity. CK peaked to 11,344.

MRI shows multiple ovoid to splotchy confluent lesions in the white matter with diffusion restriction. Lesions also enhanced with hyperperfusion (not shown).

Urine drug test positive for cocaine. Infectious work-up was negative. Steroids were started with good recovery.

Patient denied knowingly taking cocaine but did say weekly use of what they thought was MDMA with friends…

Final diagnosis: Levamisole-induced leukoencephalopathy. Levamisole is an antiparasite medication that is no longer used in the US but still in some other countries. It is a common cutting agent in cocaine. It’s neurotoxic effects primarily come from causing demyelination.