Levamisole-Adulterated Cocaine Induced Skin Necrosis of Nose, Ears, and Extremities: Case Report

Abstract

Levamisole is an immunomodulatory and antihelminthic drug, previously removed from the United States market, and now estimated to be present in the vast majority of cocaine distributed in the United States. Levamisole-adulterated cocaine (LAC) exposure can result in neutropenia, thrombocytopenia, and vasculitis with a predilection for subsites of the face. The objective of this review is to increase awareness among otolaryngologists of the manifestations of LAC exposure. We present the case of a 33-year-old woman with a history of cocaine use, consulted for purpuric, necrotic lesions of the nose, cheeks, and ears, with accompanying leukopenia, thrombocytopenia, and positive antineutrophil cytoplasmic antibodies (ANCA). The effects of levamisole are immune mediated, with antibodies directed against neutrophils causing neutropenia, and vasculitis caused by antibody deposition or secondary to induction of antiphospholipid antibodies causing thrombosis. LAC exposure can be differentiated from other similar appearing pathologies by evaluating serology for specific ANCA. The most important treatment is cessation of cocaine use, which most often results in complete resolution of symptoms. Awareness of the presentation, complications, and treatment of LAC exposure may be especially important for otolaryngologists, who may be one of the firsts to evaluate an affected patient.

Extensive Necrotic Purpura in Levamisole‐Adulterated Cocaine Abuse – A Case Report

“…Immunologic investigations showed positive pANCA (HNE and MPO) and type III cryoglobulinemia with limit range for ANA. Based on a previous study and reviews , pANCA are more commonly observed than cANCA (in approximately 40% in Larocque et al 2012 ), with positive anti‐MPO in approximately 25%. Positive anti‐PR3 or positive cANCA have been observed, and no specific immunologic profile was reported in the literature.…”

“…Previous results from animal and ex vivo or in vitro studies suggest an enhancement of the stimulant effect of cocaine, but the precise mechanism has not been detailed. The main hypothesis suggests that levamisole may enhance noradrenergic neurotransmission, possibly by inhibiting reuptake, inhibiting monoamine oxidase (MAO) or catechol‐o‐methyl transferase (COMT), ganglionic nicotinic receptor changing, or a potential and partial human metabolism in amphetamine‐like drugs . Those mechanisms may explain the frequent use of levamisole in cocaine even though its price is higher than paracetamol or caffeine .…”

“…The clinical reports and reviews of the medical literature, which consist of approximately 203 and 32 levamisole cases, respectively, demonstrate that the majority of those affected are women (55–75%) with a mean age of approximately 42–45 years old, and the cocaine is usually snorted or smoked (when noted). Levamisole was detected in only 28% of cases, cutaneous lesions were present in 40–50% of all cases, and the recurrence of symptoms after cocaine/levamisole re‐exposure was observed to be between 27–50%.…”

“…Positive anti-PR3 or positive cANCA have been observed, and no specific immunologic profile was reported in the literature. Anti-HNE seems to be interesting, in particular for levamisole intoxication, due to its observation in many cases in association with anti-MPO (1,15,(17)(18)(19)(20)(21). Furthermore, anti-HNE is currently observed in cocaine-induced midline destructive lesions (CIMDL) without anti-MPO.…”

Levamisole‐induced cutaneous vasculitis

“…Levamisole is an immunomodulatory and antihelminthic drug that is used as a bulking agent in cocaine to enhance the stimulatory effects. 2 A diagnosis of LIV requires a high degree of suspicion. This is based on the combination of typical cutaneous findings, unusual antibody patterns, a procoagulant state, histology and resolution of symptoms on drug cessation.…”