Recurrent Levamisole-Induced Agranulocytosis Complicated by Bowel Ischemia in a Cocaine User

Abstract

Patient: Male, 59Final Diagnosis: Levamisole induced agranulocytosisSymptoms: Abdominal pain • feverMedication: —Clinical Procedure: —Specialty: Critical Care MedicineObjective:Challenging differential diagnosisBackground:Levamisole is a common adulterant of cocaine and up to 69% of seized cocaine in United States contains levamisole. It is a synthetic imidazothiazole derivative which was previously used as an immunomodulating agent for treatment of various connective tissue disorders and colorectal carcinoma. However, it was withdrawn later from the market due to significant toxicity associated with it.Case Report:We present the case of a 59-year-old male patient with a history of active cocaine use who presented to the hospital with febrile neutropenia and agranulocytosis. He underwent extensive work-up for neutropenia and was suspected to have it secondary to levamisole-adulterated cocaine. He was treated with antibiotics and granulocyte-stimulating factor. His white cell count improved and he was discharged home. He continued to use cocaine after discharge from the hospital. He returned to the hospital 3 weeks later with recurrent neutropenia and agranulocytosis complicated by septic shock and bowel necrosis which required prolonged antibiotics and a bowel resection.Conclusions:Levamisole-induced agranulocytosis should be considered in patients who present with neutropenia and a history of cocaine use. Physicians should have high clinical suspicion and consider it a potential etiology of agranulocytosis when other causes have been excluded.

DARK Classics in Chemical Neuroscience: Aminorex Analogues

“…Cocaine is one of the most frequently consumed illicit substances, and global cocaine production has been increasing during the last couple of years. , Common adulterants in cocaine include acetaminophen, acetylsalicylic acid, caffeine, lidocaine, (synthetic) cathinones, hydroxyzine, and levamisole . The latter is currently the most frequently found adulterant, with reports suggesting that between 60% and 80% of all investigated cocaine samples are adulterated with levamisole. − The abuse of levamisole-adulterated cocaine has been thoroughly documented and is associated with influenza-like symptoms, ANCA (antineutrophil cytoplasmic antibody) positive and negative vasculitis, causing retiform purpura and glomerulonephritis, pyoderma gangrenosum, cutaneous necrosis (often of the ears, face and/or legs), neutropenia or agranulocytosis, leukocytopenia, and multifocal inflammatory leukencephalopathy. − The media has picked up this story and reports about “flesh-eating cocaine” surface from time to time. − …”

Simple Strategy for Selective Determination of Levamisole in Seized Cocaine and Pharmaceutical Samples Using Disposable Screen‐printed Electrodes

“…It also may be used due to synergetic effects and increase in the drug action duration . LEV is also an anthelmintic agent used in veterinary medicine and its use associated with cocaine can cause neutropenia and agranulocytosis .…”

Does the Route of Cocaine Use Affect the Mortality and Outcomes of Cocaine-Induced Intestinal Ischemia? A Systematic Review

“…In addition, there were 45 case reports among the included articles. 2 - 4 , 8 - 49 In addition to case reports, there were case series. 1 , 50 - 56 In the final step, manuscripts where the route of cocaine consumption was missing were excluded.…”