Necrosis of Ears after Use of Cocaine Probably Adulterated with Levamisole

Abstract

Background/Aims: Levamisole is an anthelminthic drug with immunomodulatory properties that has been found to be an adulterant of cocaine in the last 2 years. It was present at least in 70% of tainted cocaine in the USA in 2009. Methods: We present the case of a 40-year-old patient with a history of weekend cocaine use who consulted for bilateral necrotic lesions in the ears that had appeared 3 days after the last use. Results: Levamisole causes a typical clinical picture characterized by bilateral necrosis of the ears, positive perinuclear antineutrophil cytoplasmic antibodies and laboratory findings of antiphospholipid syndrome, such as anticardiolipin antibodies and/or lupus anticoagulant. Conclusion: Dermatologists should be aware of this new entity, which is likely to be more and more frequent due to the increasing use of cocaine. Here we describe a clinical case that is likely to be secondary to levamisole-tainted cocaine and review the literature.

Detection of Cutting Agents in Drug‐Positive Seized Exhibits within the United States

“…Studies show that >65% of cocaine samples on the illegal drug market contain levamisole (30)(31)(32)(33). It is believed that levamisole inhibits dopamine reuptake in presynaptic terminals of neurons, consequently enhancing the euphoric effects of cocaine (33)(34)(35)(36)(37). Another theory is the potentiation of the nicotinic acetylcholinergic effects on the central nervous system resulting in a prolongment of cocaine-induced euphoria (24,28).…”

Levamisole Induced Autoimmunity

“…It is not known if these autoantibodies are pathogenic and can cause thrombosis, or if on the contrary, they represent only an epiphenomenon. We did not find any reported case of thrombotic events in this context [13]. Treatment has been documented in 52 of the 62 reviewed cases.…”

“…During the following years more than 200 levamisole contaminated cocaine induced vasculitis (LCIV) cases were reported in literature [6][7][8][9][10][11][12]. The presence of levamisole is difficult to prove because it has a short halflife, only 5-7% can be detected in urine, and specific diagnostic tools (gas chromatography and mass spectrometry) are required [13]. Only 57 patients have levamisole confirmation [6][7][8][9][10][11][12][13].Treatment consists of stopping levamisole use and supportive measures.…”

“…The presence of levamisole is difficult to prove because it has a short halflife, only 5-7% can be detected in urine, and specific diagnostic tools (gas chromatography and mass spectrometry) are required [13]. Only 57 patients have levamisole confirmation [6][7][8][9][10][11][12][13].Treatment consists of stopping levamisole use and supportive measures. We aim to describe a new form of presentation of levamisle vasculopathy that persisted long after suspension.…”

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

“…Although cocaine use is more prevalent in men as per SAMHSA, females are predominant in cases of cutaneous vasculopathy [24 && ]. Although the pathophysiology of these cutaneous vascular lesions is not fully understood, patients commonly have diffusely positive serum autoantibodies including antineutrophil cell wall antibodies, cytoplasmic and p-ANCA, and antibodies to cardiolipin (usually immunoglobin M type), double-stranded DNA, ribonucleoprotein, and antiphospholipid antibodies [26,29]. The typical histological features include a pure small vessel vasculitis, thrombotic vasculopathy, or mixed picture of vasculitis and thrombosis [24 && ,30 && ].…”