Levamisole-adulterated cocaine: a case of retiform purpura, cutaneous necrosis and neutropenia

A Case of Levamisole-Induced Agranulocytosis

“…Also, levamisole acts as a hapten increasing the formation of antibodies to granulocyte antigens and triggering an immune response resulting in destruction of leukocytes [ 1 , 4 ]. Another explanation is that it could serve as a substrate for myeloperoxidase to form reactive metabolites that might stimulate autoimmunity [ 5 ].…”

“…Levamisole levels can be detected in urine and plasma by gas chromatography mass spectroscopy. The timing is important since the half-life of levamisole is only 5.6 hours and remains detectable for 2-3 days after initial exposure [ 5 , 7 ]. Bone marrow biopsy in such patients reveals a hypercellular bone marrow with a relative myeloid hypoplasia.…”

Painful Violaceous Purpura on a 44-Year-Old Woman

“…4 While levamisole-adulterated cocaine is a commonly recognized cause of agranulocytosis, it has more recently been implicated as a cause of vasculitis that presents with retiform purpuric patches with or without hemorrhagic bullae and cutaneous necrosis. Cutaneous findings have been reported upon in the literature after both intravenous and inhaled use of cocaine 5,6 .…”

Antineutrophil cytoplasmic antibodies negative levamisole‐induced leukocytoclastic vasculitis: a presumed case and literature review

“…Levamisole is an immunomodulatory chemical originally used to treat colon adenocarcinoma and nephrotic syndrome in children . However, it was withdrawn from the United States market in 2000 by the United States Food and Drug Administration and the Canadian market in 2003 due to serious side effects including neutropenia, agranulocytosis, autoimmune antibodies, hepatosplenomegaly, arthralgia, retiform purpura, and full thickness cutaneous necrosis . Levamisole is also used as a veterinary antihelminthic; however, it has been repurposed as an agent to cut cocaine due to its low cost, similarity in gross appearance, and ability to bypass rudimentary street purity tests .…”

“…[1][2][3][4] However, it was withdrawn from the United States market in 2000 by the United States Food and Drug Administration and the Canadian market in 2003 due to serious side effects including neutropenia, agranulocytosis, autoimmune antibodies, hepatosplenomegaly, arthralgia, retiform purpura, and full thickness cutaneous necrosis. [2][3][4][5][6] Levamisole is also used as a veterinary antihelminthic; however, it has been repurposed as an agent to cut cocaine due to its low cost, similarity in gross appearance, and ability to bypass rudimentary street purity tests. 5,7,8 Additionally, as a nicotinic agonist, levamisole induces glutamate release, thereby potentiating the psychotropic effects of cocaine.…”