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No guidelines exist regarding the management of cocaine-induced toxic leukoencephalopathy, with variable reports as to the effect of steroid treatment on outcome. We describe the case of a 51-year-old gentleman who presented to the emergency department obtunded following a suspected overdose. Urine toxicology was positive for cocaine. He was admitted to intensive care for a period of multi-organ support, and following stepdown to a medical ward was found to have perseveration of speech and dysphasia. Addenbrooke’s Cognitive Examination (ACE)-R revealed significant cognitive impairment, with an initial score of 25/98. Neurological examination was otherwise normal. A diagnosis of cocaine-induced toxic leukoencephalopathy was made based on suggestive magnetic resonance brain imaging (MRI) changes, with symmetrical, abnormal high T2-weighted signal, and mild diffusion restriction throughout the cerebral white matter. Treatment with high-dose prednisolone was initiated at 60mg once daily, with a planned dose reduction of 10mg every five days. Improvement was noted on serial MRI and cognitive assessment, with near complete recovery achieved following a period of neurorehabilitation, and a score of 89/100 on ACE-III at the end of treatment. This case, in combination with some of the pre-existing literature, may prompt consideration of corticosteroids in patients with a similar presentationa.hamilton-shield@nhs.net