Agranulocytosis and other consequences due to use of illicit cocaine contaminated with levamisole

Buchanan, Jennie

doi:10.1097/moh.0b013e32834da9ef

Cited by 33 publications

(39 citation statements)

References 35 publications

(34 reference statements)

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“…The latter highlight the risk inherent in adulteration of street drugs, namely the occurrence of severe or life-threatening intoxications. Therefore it is important to mention that consumption of cocaine adulterated with levamisole not only provokes severe agranulocytosis (Buchanan and Lavonas, 2012) but also induces the risk of pulmonary hypertension due to aminorex (Fishman, 1999b). …”

Section: Discussionmentioning

confidence: 99%

Aminorex, a metabolite of the cocaine adulterant levamisole, exerts amphetamine like actions at monoamine transporters

Hofmaier

Luf

Seddik

et al. 2014

Neurochemistry International

102

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HighlightsWe quantified adulterants in street drugs sold as cocaine.We analyzed effects of the most common adulterant levamisole, on neurotransmitter transporters.Differences in the selectivity of levamisole can be explained by homology modelling and docking.Aminorex, a metabolite of levamisole, modulates neurotransmitter transporters directly.Depending on the transporter, aminorex acts as a blocker or as a releaser.

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Section: Discussionmentioning

confidence: 99%

Aminorex, a metabolite of the cocaine adulterant levamisole, exerts amphetamine like actions at monoamine transporters

Hofmaier

Luf

Seddik

et al. 2014

Neurochemistry International

102

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“…In particular, levamisole has been implicated since its use is recent and it can be found in up to 65% of cocaine samples 3,6 and in urine of patients positive for cocaine 7 . In addition, the medication has been directly associated with leukoencephalopathy [8][9][10][11] . The pathology is believed to be similar to other spongiform encephalopathies, where fluid entrapment is found in small vacuoles within the myelin lamellae 1 .…”

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confidence: 99%

Cocaine-Induced Recurrent Leukoencephalopathy

González‐Duarte

Williams²

2013

Neuroradiol J

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SUMMARY -Cocaine-induced leukoencephalopathy is a rare neurological complication. It is most likely related to the substances used to adulterate the cocaine. Levamisole is one of the most common Case ReportA 40-year old woman with chronic daily use of cocaine was admitted to the ER for acute onset of confusion, altered language and mild fever. At entry, her blood pressure was 110/70 mmHg, temperature was 38.5ºC and she exhibited motor aphasia. The rest of the examination was normal. Laboratory tests were within normal limits and HIV was negative. A lumbar puncture showed leucocytes of 200 cells/ mm 3 (75% PMN, 25% MN), glucose of 85 mg/dl, proteins of 35 mg/dl, negative gram and fungal stains, and negative PCR for HSV-1 and 2 and Mycobacterium tuberculosis. Serum HIV and skin tuberculin tests were negative. T2 and FLAIR sequences of the brain MRI displayed areas of hyperintense signal in the white matter of the left parietal lobe ( Figure 1A,B). The DWI/ADC sequences and resonance angiography were normal. Presumptive treatment for an incipient brain abscess was initiated with ceftriaxone, metronidazole and dexamethasone. A transesophageal echocardiogram was normal. ENT and dental evaluations did not reveal any focus of infection. The blood and CSF cultures taken at entry were negative. The patient recovered completely after two days. A follow-up lumbar puncture after ten days showed leucocytes of 10 cells/mm 3 , glucose of 72 mg/dl and proteins of 17 mg/dl, but the MRI indicated only mild improvement of the lesion. Because she was asymptomatic, she was discharged after 14 days of IV antibiotics.Ten days later she began experiencing sudden visual changes and weakness of the left arm. MRI showed resolution of the previous lesion but displayed a new one in the right frontal lobe ( Figure 1C,D). She was readmitted and IV imipenem, linezolid and dexamethasone were begun. The patient recovered completely after a few days. Serum antibodies against Borrelia and Hystoplasma, anti-phospholipid and antinuclear antibodies were negative. A lung biopsy of a small nodule was negative for granulomas, stains and cultures. After one week she was discharged with the same IV treatment administered by a nurse at her home.Seven days later she had a new episode consisting of motor aphasia. The patient was unable to talk, read or write. The MRI showed a third lesion in the left frontal lobe with resolution of the previous lesions ( Figure 1E,F). The patient and her family refused a brain biopsy. A spinal MRI did not show spinal lesions consistent with autoimmune demyelinating disease. PET-CT ( Figure 1G,H) failed to show lesions suggestive of lymphoma. Complete clinical recovery was achieved within two weeks. After the last episode she admitted she had consumed cocaine at home. After a year of follow-up she has not presented new episodes.

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“…Levamisole is normally limited to veterinary medicine and has been used to cut cocaine given its similar appearance and taste [60]. It has also been reported that more than 75% of cocaine users in the US are exposed to levamisole [62]. Levamisole-adulterated cocaine seized by the US Food and Drug Administration (FDA) was first reported in April 2005 and 69% of seized cocaine was contaminated with levamisole by 2009 [58].…”

Section: Levamisole-adulterated Cocaine-associated Antineutrophil Cytmentioning

confidence: 99%

“…Laboratory abnormalities include leukopenia, neutropenia, high-titer MPO-ANCA, PR3-ANCA, ANA and antiphospholipid autoantibodies [64 && ,65]. Urine levamisole in the appropriate clinical setting is highly suggestive of drug-induced disease, although the test can be negative if exposure occurred more than 24 h prior to testing given that the estimated mean half-life of blood levamisole is 5.6 h [58,62]. In fact, a patient with doublepositive MPO-ANCA and PR3-ANCA is becoming pathognomonic for this disease entity [63].…”

Section: Levamisole-adulterated Cocaine-associated Antineutrophil Cytmentioning

confidence: 99%

Trojan horses

Pendergraft

Niles²

2014

Current Opinion in Rheumatology

136

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Hydralazine, minocycline, propylthiouracil and levamisole-adulterated cocaine use should be closely considered in any patient where ANCA vasculitis is entertained given the wide use of these drugs in the community. Furthermore, medical practitioners should test urine for the presence of cocaine in any patient with presumed ANCA vasculitis, and if positive, then urine should also be tested for levamisole. Clinical features can be severe requiring not only drug cessation and supportive care, but also immunosuppression, plasma exchange in severe cases and dialysis as needed. Clinical trial investigators should strongly consider excluding patients with drug-induced forms of disease and mechanistic inroads are greatly needed in these secondary forms of disease to help elucidate the underlying cause and pathogenesis of ANCA vasculitis.

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Agranulocytosis and other consequences due to use of illicit cocaine contaminated with levamisole

Cited by 33 publications

References 35 publications

Aminorex, a metabolite of the cocaine adulterant levamisole, exerts amphetamine like actions at monoamine transporters

Aminorex, a metabolite of the cocaine adulterant levamisole, exerts amphetamine like actions at monoamine transporters

Cocaine-Induced Recurrent Leukoencephalopathy

Trojan horses

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