Levamisole-Adulterated Cocaine Toxicity: Would You Recognize It?
2
Citation
0
Reference
10
Related Paper
Citation Trend
Abstract:
Article AbstractAdulteration of cocaine with levamisole is common and can induce serious medical complications. Levamisole is an antihelminthic agent originally approved as an immunomodulator in the treatment of autoimmune disorders and as a chemotherapy adjunct. It was withdrawn from the US market in 2000 but is available in veterinary medicine. Cocaine-using patients may present with nonspecific constitutional symptoms, cutaneous eruptions, leukopenia, vasculitis, and organ damage. Skin manifestations may include severe necrosis, especially of the ear lobes. Here, a case of levamisole toxicity is presented and treatment options are discussed.Keywords:
Levamisole
Leukopenia
Levamisole is an antihelminth drug and a common cocaine contaminant, present in an estimated 71% of cocaine samples in the US. Levamisole-contaminated cocaine has been linked to an ANCA-associated vasculitis with cutaneous, renal, and pulmonary manifestations. We report the case of a 46 year old woman with known cocaine exposure who presents with recurrent, large purpuric and maculopapular rash of the extremities and face and review existing cases of levamisole/cocaine-associated ANCA vasculitis, We summarize the clinical presentation, treatment, and outcomes of levamisole induced vasculitis. There is emerging research on pathogenesis relating to neutrophil extracellular traps (NETs). We review studies implicating role of NETs in the pathogenesis of levamisole induced vasculitis. Further research to explore the use of NETs as therapeutic targets in drug induced vasculitis is needed.
Levamisole
Pathogenesis
Neutrophil Extracellular Traps
Cite
Citations (60)
Levamisole
Purpura (gastropod)
Cite
Citations (1)
Levamisole adulterated cocaine is a rare cause of anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis. It is increasingly diagnosed because of raised awareness; however, it is still underdiagnosed in part because of its rarity and patients not reporting cocaine use. Here we report a case of levamisole-induced vasculitis. We present a 48-year-old non-Hispanic white male with a past medical history significant for Crohn's Disease and pneumonia who presented with acute bilateral ear pain and rash. His urinary drug screen was positive, which prompted suspicion of contamination and potential levamisole adulterated cocaine-associated vasculitis. A punch biopsy showed evidence of leukocytoclastic vasculitis and multiple fibrin thrombi further supporting contamination with levamisole. We believe this case highlights the importance of using patient history in guiding diagnostic testing in the setting of acute vasculitis. Once the history of illicit substance use was confirmed, our differential diagnosis and considerations for treatment significantly changed.
Levamisole
Medical History
Cocaine use
Past medical history
Cite
Citations (5)
A significant amount of cocaine used in the United States today is adulterated with levamisole. In some instances, prolonged use of contaminated cocaine is associated with the development of levamisole-induced vasculitis (LIV) with features of cutaneous vasculitis and agranulocytosis along with other constitutional symptoms and arthritis. We describe a case of a crack cocaine user with LIV, who developed significant renal disease secondary to crescentic glomerulonephritis, confirmed on renal biopsy. Renal vasculitis is an uncommon feature of LIV and significantly affects clinical course and management.
Levamisole
Rapidly progressive glomerulonephritis
Cite
Citations (9)
Levamisole is a veterinary antihelminthic drug that, in the past, was a US Food and Drug Administration-approved drug in humans used to treat various cancers and rheumatoid arthritis because of its immunomodulating effects; however, it is not longer used in the United States since 2000, because of multiple adverse side effects including agranulocytosis and vasculitis. Drug-induced vasculitis is a challenging diagnosis. It is important to recognize that levamisole may not only induce ANCA-associated vasculitis but also other autoimmune markers abnormalities. This case discusses the possibility of levamisole-induced vasculitis and the need to pursue further testing to establish causality in ANCA-associated vasculitis. J Med Cases. 2018;9(1):19-20 doi: https://doi.org/10.14740/jmc2965w
Levamisole
Leukocytoclastic vasculitis
Cite
Citations (0)
Levamisole is a veterinary antihelminthic drug that, in the past, was a US Food and Drug Administration-approved drug in humans used to treat various cancers and rheumatoid arthritis because of its immunomodulating effects; however, it is not longer used in the United States since 2000, because of multiple adverse side effects including agranulocytosis and vasculitis. Drug-induced vasculitis is a challenging diagnosis. It is important to recognize that levamisole may not only induce ANCA-associated vasculitis but also other autoimmune markers abnormalities. This case discusses the possibility of levamisole-induced vasculitis and the need to pursue further testing to establish causality in ANCA-associated vasculitis. J Med Cases. 2018;9(1):19-20 doi: https://doi.org/10.14740/jmc2965w
Levamisole
Cite
Citations (0)
While the usage of illicit drugs in itself carries significant health risks and associated toxicities, drugs that are adulterated to give them volume, alter their psychogenic properties, and make them cheaper to produce are to be considered even more dangerous. Cocaine is one of them, and it is now most commonly being adulterated with levamisole. We report a case of a 37-year-old female with the chief complaint of painful skin lesions and wounds on both of her upper and lower extremities for three weeks duration. She was tested positive for cocaine and had classical purpuric, ecchymotic, and necrotic patches on both ears, which are pathognomonic. She also had multiple wounds in extremities. The cocaine-levamisole related syndrome comprises a set of immunological abnormalities, out of which, ANCA positivity is the most important one. Our patient was ANCA positive. Regarding pathological findings in cocaine adulterated with levamisole syndrome, this can range from the classic finding of leukocytoclastic vasculitis of small vessels to occlusive vascular disease without true vasculitis. Our case's biopsy showed no vasculitis, and this is why it is important to highlight that cocaine can also cause a pseudo-vasculitic picture. The other possibility that we entertained was that of pyoderma gangrenosum as the skin finding in levamisole-contaminated cocaine, and the lesion was consistent in appearance. Recently, there have been a few case reports of pyoderma gangrenosum from adulterated cocaine with levamisole, where skin findings were consistent with pyoderma gangrenosum; however, serological findings rather favored levamisole vasculopathy or vasculitis. Therefore, we should familiarize ourselves with the multitude of pathological and skin findings that adulterated cocaine can cause and, finally, make ourselves aware that the classical pathological finding of vasculitis in such cases is not always seen.
Levamisole
Cocaine use
Skin biopsy
Cite
Citations (2)
Abstract: Levamisole, an anthelmintic and immunomodulatory drug, was withdrawn from the US market in 1999 due to adverse effects, including agranulocytosis and vasculitis. In recent years, levamisole has been used as a common cocaine adulterant, and its use has led to an autoimmune syndrome characterized by an antineutrophil cytoplasmic antibody–associated vasculitis presenting with necrotic retiform purpura on the face and extremities. We present a case of recurrent levamisole-induced vasculitis initially misdiagnosed as systemic lupus erythematosus to highlight this easily misdiagnosed entity and to demonstrate re-exposure leading to recurrent vasculitis with more extensive clinical manifestations.
Levamisole
Purpura (gastropod)
Cite
Citations (4)
Levamisole
Adulterant
Cocaine use
Cite
Citations (23)
목 적 : 소아의 스테로이드 의존형 및 빈번 재발형 신증후군에 사용되는 스테로이드 장기투여, cyclophosphamide, cyclosporin등은 성장 장애나 생식선 장애, 신독성등 여러 가지 부작용을 일으킬 수 있다. 이에 저자들은 최근 시도되고 있는 면역 조절제인 levamisole을 스테로이드 의존형 신증후군 환아에게 투여하여 이의 효과와 부작용을 관찰하고, 또한 기존의 제제를 사용한 치료 효과와 비교하고자 본 연구를 시행하였다. 대상 및 방법 : 대상환아는 1990년부터 2000년까지 연세대학교 세브란스병원 소아과에서 cyclophosphamide, cyclosporin등의 면역 억제 치료를 받고도 만족할 만한 관해가 유지되지 못하고 자주 재발하는 스테로이드 의존형 신증후군 환아 16례로 하였다. 치료시작 당시 연령분포는 3.7세에서 13.2세까지 평균 $9.1{\pm}2.5세$ 였고, 남녀비는 15:1이었으며, 조직검사상 모두 MCNS로 진단되었다. 이들에게 levamisole을 1일 체중당 2.5 mg을 격일 요법으로 12개월간 경구 투여하고 스테로이드 제제를 감량 투여하며 재발빈도, 치료결과를 조사하였다. 결 과 : Levamisole 치료를 받았던 환아들은 치료 시작 평균 14일에 모든 환아에서 완전 관해를 나타내었으며 1년간의 치료기간중 재발하지 않은 경우가 8례( $50\%$ )였으며, 재발한 경우도 8례였다. 치료 기간중 평균 재발 횟수는 연간 $0.77{\pm}0.9회$ 로 치료전의 연간 $2.18{\pm}0.9회$ 회에 비해 의미있게 감소하였으며(P=0.027), 치료후 평균 재발 횟수 역시 연간 $1.34{\pm}1.1회$ 로 치료전에 비해 의미있게 감소하였다(P=0.003). Levamisole 치료전 관해 유지 기간은 평균 $12.2{\pm}9.1개월$ 이었고, levamisole 치료후의 관해 유지 기간은 평균 $10.1{\pm}6.9개월$ 로 의미있는 차이가 없었다. Levamisole 치료후 나타날 수 있는 leukopenia, 피부 질환 및 그외의 임상적으로 의미있는 부작용은 나타나지 않았다. 결 론 : 스테로이드 의존형 신증후군 환아의 치료에서 levamisole의 장기사용은 큰 부작용없이 재발의 빈도를 감소시켜 안정적 관해 유지를 기대할 수 있을 것으로 생각되며, 관해 유지 기간은 levamisole 치료전 다른 치료를 했을 때와 별 차이가 없었으나 좀 더 많은 환자를 대상으로 치료 후 장기간의 추적관찰이 필요할 것으로 사료된다. 【Purpose Long- term use of steroid, cyclophosphamide and cyclosporin, which are frequently used in the therapy of SDNS, might cause severe side effects. Recently, the immune-modulator levamisole has been tried as a substitute therapy and it has been reported as a method with less side effects and more effectiveness. We started this research in order to observe the effects of levamisole and compare it to other therapy results. Patients and Methods : We chose 16 steroid dependent nephrotic syndrome children, those who had shown frequent relapse during the immunocompromised therapy period. Mean age was $9.1{\pm}1.4$ years in children and the male to female ratio was 15:1. All of subjects were diagonized with MCNS and had received cyclophosphamide or cyclosporin before receiving levamisole. Levamisole at a dose of 2.5mg/kg was used every other day for 1 year and the relapse rate was observed. Results : On average of 14 days after treatment, complete remission was visible in all of the children, and the relapse percentage was $50\%$ , which represents 8 children, while remaining 8 children representing $50\%$ of the cases showed no relapse during treatment. During the levamisole therapy period, tile average relapse rate was reduced significantly from $2.18{\pm}0.9/year\;to\;0.77{\pm}0.9/year$ (P=0.027). Also the average relapse rate after the therapy was reduced to $1.34{\pm}1.1/year$ , which was a significant level compared to the level before treatment(P=0.003). There was no significant difference in terms of duration of remission maintenance. Duration of remission maintenance showed an average of $12.2{\pm}9.1$ months before the use of levamisole, but it was also $10.1{\pm}6.9$ month after therapy. No other side effects such as leukopenia, skin disease and other clinically significant symptoms appeared at all during therapy. Conclusion : The long-term medication of levamisole for the therapy of SDNS children is thought to be able to maintain stable remission by reducing the relapse frequency without causing severe side effects. Further study with a broader range of subjects is required to eluccidate the long-term effects of this treatment. (J. Korean Soc Pediatr Nephrol 2001;5 : 109-16)】
Levamisole
Leukopenia
Cite
Citations (0)