December 2017

Levamisole in cocaine causes agranulocytosis and neutropenia:  Skin necrosis, renal issues, and/or opportunistic infections

  • Cases of agranulocytosis, neutropenia, and vasculitis related to cocaine use continue to be seen in toronto
  • These illnesses are due to an adulterant, levamisole, a chemical compound used to treat worms in animals, rather than from the cocaine itself.  Individuals in Toronto, and across North America, have developed immune system suppression after using cocaine.
  • A large percentage of cocaine entering North America continues to be cut with levamisole.
  • Although cases have been found across age and gender, female cases have been more frequent.

Clinical Signs and Symptoms

  • Presentations include fever, opportunistic infections, and/or skin necrosis.
  • In a cocaine user or suspected cocaine user, any symptoms of rapidly developing infection, including fevers, warrant an urgent CBC and differential to look for neutropenia.  The neutropenia is acute and profound, commonly with a neutrophil count of zero. The total white blood cell count may only be slightly below normal as the lymphocytes and other white blood cells can be normal.
  • Neutrophil count generally recovers within 10 days after cocaine use is discontinued.
  • Urine toxicology can be sent simultaneously looking for cocaine and levamisole. However, levamisole has a short detection “window” in urine (specimen should be collected within 24 h of last use).
  • Organ involvement is also possible with several case reports of both renal and lung disease that is most commonly expressed as pauci-immune glomerulonephritis and pulmonary hemorrhage, respectively.

Some people having severe reactions to levamisole may be positive for HLA-B27 genotype.

Sample of early phase skin lesion on an ear
Early phase skin lesions
Sample of an early phase skin lesion on a leg.
Early phase skin lesions
Sample of mid-phase skin lesion on tip of the nose and cheek
Mid phase skin lesions

Diagnostics and Testing

  • Urine toxicology can be sent simultaneously looking for cocaine and levamisole. However, levamisole has a short detection “window” in urine (specimen should be collected within 24 h of last use).
  • Some people having severe reactions to levamisole may be positive for HLA-B27 genotype.

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