Levamisole tainted cocaine causing severe neutropenia in Alberta and British Columbia

Abstract

BackgroundFive cases of severe neutropenia (neutrophil counts < 0.5 per 109 cells/L) associated with exposure to cocaine and levamisole, an antihelimithic agent no longer available in Canada, were identified in Alberta in 2008. Alberta and British Columbia (BC) public health officials issued an advisory and urged health care professionals to report cases to public health. This paper presents the findings of the public health investigations.MethodsCases were identified prospectively through reporting by clinicians and a retrospective review of laboratory and medical examiners data from January 1, 2006 to March 31, 2009. Cases were categorized as confirmed, probable or suspect. Only the confirmed and probable cases are included in this paper.ResultsWe compare cases of severe neutropenia associated with tainted cocaine (NATC) identified in Alberta and BC between January 1, 2008 to March 31, 2009. Of the 42 NATC cases: 23(55%) were from Alberta; 19(45%) were from British Columbia; 57% of these cases reported crack cocaine use (93% of those who identified type of cocaine used); 7% reported using cocaine powder; and the main route of cocaine administration was from smoking (72%). Fifty percent of the NATC cases had multiple episodes of neutropenia associated with cocaine use. Cases typically presented with bacterial/fungal infections and fever. One Alberta NATC case produced anti-neutrophil antibodies, and four were positive for anti-neutrophil cytoplasmic antibody (ANCA). Analysis of two crack pipes and one drug sample obtained from NATC cases confirmed the presence of both cocaine and levamisole. A further 18 cases were identified through the retrospective review of laboratory and medical examiner data in AlbertaInterpretationOur findings support a link between neutropenia and levamisole tainted cocaine; particularly from smoking the crack form of cocaine. Some patients may be genetically predisposed to develop levamisole-related neutropenia. Awareness of the differential diagnosis will assist clinicians with case timely detection and appropriate management.

Levamisole-Induced Vasculitis: A Characteristic Cutaneous Vasculitis Associated With Levamisole-Adulterated Cocaine

“…3,13,14 Levamisole has been detected in cocaine since 2003, and detection has only increased in recent years. 14,15 Levamisoleinduced vasculitis was originally described in 1978 in a patient being treated for rheumatoid arthritis and has been described in children receiving treatment for nephrotic syndrome. 2,4 However, because levamisole is no longer in clinical use, the reported cases today are exclusively from users of levamisoleadulterated cocaine.…”

Genetic determinants of cocaine-associated agranulocytosis

“…Case reports included patient demographics, clinical information, and past medical history [6, 19]. Eligible cases were recruited through study invitation letters distributed by the reporting physician with an invitation to contact a research team member for enrollment.…”

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

“…Most patients who developed agranulocytosis did so after smoking cocaine, but it is not clear whether smoking 'crack' or freebase cocaine is associated with greater risk than other routes of exposure [20]. Relapse is common; approximately half of the patients had more than one episode of agranulocytosis associated with return to cocaine abuse [20]. Although isoimmune antineutrophil cell wall antigens are thought be…”