Levamisole toxicity

Background

  • An antihelminthic and immunomodulator that has been withdrawn from the U.S. and Canadian markets, due to the risk of serious side effects
  • Increasingly used as a cutting agent in cocaine sold around the globe
    • 69% of DEA seized cocaine contained levamisole (2009)[1]
  • Results in Levamisole induced necrosis syndrome[2]

Clinical Features

Leviamisole induced retiform purpura with hemorrhagic bullae in a patient with cocaine abuse[3]
  • Agranulocytosis/Thrombocytopenia
    • Typically neutropenia
    • Tends to reverse spontaneously when discontinued
  • Levamisole induced necrosis syndrome
    • Necrotic patches anywhere on skin (especially ears and legs)
  • Leukoencephalopathy
    • Seen when used as a pharmaceutical in past
    • No cases described when associated with cocaine adulteration

Differential Diagnosis

Necrotizing rashes

Evaluation

  • CBC

Management

  • Neutropenia
  • Necrosis
    • Aggressive supportive care
    • Burn care if significant necrosis
  • Avoid cocaine re-exposure
    • 27% of patients had symptom recurrence with cocaine re-exposure[4]

Disposition

Admission

See Also

External Links

References

  1. Larocque, L. Hoffman, R. Clinical Toxicology: Levamisole in cocaine: Unexpected news from an old acquaintance. (2012), 50, 231-234
  2. http://www.ncbi.nlm.nih.gov/pubmed/20668440
  3. Cocaine-induced delayed recurrent vasculitis: a 4-year follow-up. Yogarajah M, Pervil-Ulysse M, Sivasambu B - Am J Case Rep (2015)
  4. Larocque, L. Hoffman, R. Clinical Toxicology: Levamisole in cocaine: Unexpected news from an old acquaintance. (2012), 50, 231-234