A retrospective review of four patients with severe nasal destruction secondary to cocaine adulterated with levamisole

Abstract

Cocaine is a commonly used illicit drug that is associated with cocaine-induced midline destructive lesions (CIMDLs). It is increasingly adulterated with levamisole, which has been shown to cause levamisole-induced vasculitis (LIV), a systemic vasculitis with ENT repercussions. Approximately 976 000 people aged 16-59 used powder cocaine in 2018/19 in the UK. 1 Levamisole, initially marketed in 1971 as an anti-helminthic drug, was removed from the US market in 2000 due to adverse effects, such as vasculitis. 2,3 It adds weight to cocaine and may potentiate its euphoric effect. 4 Approximately 70% of seized cocaine contained levamisole, and the proportion of cocaine "cut" with levamisole is increasing globally. 4 Whilst the prevalence of CIMDL and LIV is small compared with overall cocaine use, clinical repercussions can be severe.

Molecular Insights and Clinical Outcomes of Drugs of Abuse Adulteration: New Trends and New Psychoactive Substances

“…Conversely, the identification and structural characterization of adulterants was primarily conducted via two-step analysis by mass spectrometry and subsequently, nuclear magnetic resonance (NMR) [ 24 , 33 , 36 ]. Capillary electrophoresis and electrochemical methods are also available [ 14 , 23 , 27 , 36 , 37 ], but the gold standard are hyphenated techniques based on liquid or gas chromatography coupled to mass spectroscopy [ 12 , 15 , 17 , 20 , 22 , 28 , 29 , 30 , 38 , 39 , 40 , 41 , 42 , 43 , 44 ].…”

“…In the remaining 20 cases, adulterants were only hypothesized based on the observed symptoms, disease or indirect sequelae or confiscated drug analysis. Suspected substances were levamisole ( n = 10), methaqualone and several benzodiazepines, caffeine and acetaminophen ( n = 1), 5F-MDMB- PINACA ( n = 7) and phenethylamine ( n = 1), asbestos ( n = 1) [ 33 , 42 , 44 , 45 , 46 , 47 , 52 , 53 , 54 , 55 , 56 ]. Considering all of the reported cases, levamisole was the most prevalent adulterating agent in street cocaine ( n = 17 cases) [ 33 , 42 , 44 , 45 , 46 , 47 , 54 , 57 , 58 , 59 , 60 , 61 , 62 ].…”

“…Generally, ANCA positivity is a marker of autoimmune pathologies including systemic autoimmune vasculitis, necrotising crescentic glomerulonephritis, inflammatory bowel disease and other autoimmune pathologies [ 63 ]. In levamisole-adulterated cocaine intoxications [ 33 , 44 , 45 , 46 , 47 , 54 , 57 , 58 , 59 , 60 , 61 , 62 ] the p- or c-ANCA positivity was associated with Cocaine Induced Midline Destructive Lesions (CIMDL) ( n = 5) [ 44 , 57 ], vasculitis ( n = 8) [ 33 , 47 , 58 , 59 , 60 , 61 ], membranous glomerulonephritis ( n = 4) [ 58 , 62 ], pyoderma gangrenosum ( n = 1) [ 54 ], neutropenia complicated with bowel necrosis ( n = 1) [ 46 ], and cerebral white matter dysfunction ( n = 1) [ 45 ]. These autoimmune pathologies were more frequent in women (100% ANCA positivity) than men (90% of ANCA positivity) [ 64 ].…”

“…Levamisole was analytically confirmed in only 7 cases, with suspected exposure based on the clinical manifestations and confirmed cocaine exposure [ 33 , 44 , 45 , 58 , 59 ]. Qualitative levamisole analysis was frequently performed in urine ( n = 5), while the quantitative confirmatory analysis was performed on hair ( n = 2) with segmental analysis.…”

Cocaine-Induced Plasma Cell Orificial “Dermatomucositis”: A More Accurate Descriptive Term for a Clearly Dermatological Entity

“…It often presents with asymmetry of the nasal passages 2 or severe destruction of the nasal septum. 3 However, the clinical–pathological profile recently presented in the literature 1 is so distinctive that, in the face of the clinical presentation with prolonged erosive thickening of the nasal passages and the upper lip, one of the initial diagnostic suspicions should be this condition. A biopsy can easily confirm the suspicion, especially in the presence of an infiltrate rich in plasma cells and eosinophils.…”