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Philip M, Karakka Kal AK, Subhahar MB, Karatt TK, Mathew B, Perwad Z, Graiban FM, Caveney MR, Sayed R, Kadry AM. Hydroxy levamisole and its phase II conjugates as potential indicators of levamisole doping in thoroughbred horses. RAPID COMMUNICATIONS IN MASS SPECTROMETRY : RCM 2023; 37:e9430. [PMID: 36382989 DOI: 10.1002/rcm.9430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/09/2022] [Accepted: 11/09/2022] [Indexed: 06/16/2023]
Abstract
RATIONALE According to previous research, aminorex is the major metabolite of levamisole; however, in the screening of levamisole-positive racehorse urine and plasma samples, aminorex could only be detected in trace amounts or not at all. In forensic laboratories, hydroxy levamisole and its phase II conjugates make it easier to confirm levamisole misuse and to differentiate between the abuse of levamisole and aminorex. This study aimed to identify the major levamisole metabolites that can be detected along with the parent drug. METHODS The study describes levamisole and its metabolites in thoroughbred horses following oral administration and in vitro with equine liver microsomes. The plausible structures of the detected metabolites were postulated using liquid chromatography combined with high-resolution mass spectrometry. RESULTS Under the experimental conditions 26 metabolites (17 phase I, 2 phase II, and 7 conjugates of phase I metabolites) were detected (M1-M26). The major phase I metabolites identified were formed by hydroxylation. In phase II, the glucuronic acid conjugates of levamisole and hydroxy levamisole were detected as the major metabolites. In plasma, the parent drug and major metabolites are detectable for up to eight days, while in urine, they are detectable for up to twenty days. Levamisole levels rapidly increased at 45 min following administration, then declined gradually until detectable levels were reached approximately 8 days after administration, according to a pharmacokinetics study. CONCLUSIONS A prolonged elimination profile and relatively high concentration of hydroxy metabolites suggest that the detection of hydroxy metabolites is imperative for investigating levamisole doping in horses.
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Affiliation(s)
- Moses Philip
- Equine Forensic Unit, Central Veterinary Research Laboratory, Dubai, United Arab Emirates
| | | | | | - Tajudheen K Karatt
- Equine Forensic Unit, Central Veterinary Research Laboratory, Dubai, United Arab Emirates
| | - Binoy Mathew
- Equine Forensic Unit, Central Veterinary Research Laboratory, Dubai, United Arab Emirates
| | - Zubair Perwad
- Equine Forensic Unit, Central Veterinary Research Laboratory, Dubai, United Arab Emirates
| | - Fatma Mohammed Graiban
- Equine Forensic Unit, Central Veterinary Research Laboratory, Dubai, United Arab Emirates
| | | | - Ramy Sayed
- Equine Forensic Unit, Central Veterinary Research Laboratory, Dubai, United Arab Emirates
| | - Ahmed Mahmoud Kadry
- Equine Forensic Unit, Central Veterinary Research Laboratory, Dubai, United Arab Emirates
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Munir F, Javaid HW, Rana MBM, Shaukat F. Ceftriaxone-Induced Reversible Agranulocytosis: A Case Report and Review of Drug-Induced Agranulocytosis. Cureus 2022; 14:e23226. [PMID: 35449634 PMCID: PMC9012477 DOI: 10.7759/cureus.23226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 11/05/2022] Open
Abstract
In the modern era of medicine, agranulocytosis is a rare occurrence. Despite significant improvement in patient survival, it still carries significant mortality. Agranulocytosis is most commonly caused by chemotherapeutic agents and numerous non-chemo drugs. As it can develop anytime during treatment and patients can remain asymptomatic, frequent cell count monitoring is an essential tool to make a timely diagnosis. An appropriate drug switch, work up to rule out infection and granulocyte colony-stimulating factor (G-CSF) injection in high-risk cases is the management. The patient should be kept under observation till the resolution of agranulocytosis. We present a case of ceftriaxone-induced agranulocytosis which was completely reversible upon stoppage of drug and granulocyte colony-stimulating factor administration. The pathogenesis of ceftriaxone-induced agranulocytosis is unknown. It is suggested to occur either by an immunologic mechanism or because of direct drug toxicity.
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Mansour J, Zulfiqar M, Umer A, Zurcher KS, Heeger A, Menias CO. Abdominal Imaging Manifestations of Recreational Drug Use. Radiographics 2020; 40:1895-1915. [PMID: 33064622 DOI: 10.1148/rg.2020200048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Recreational drug use is a burgeoning health issue worldwide, with a variety of presenting symptoms and complications. These complications can be secondary to the toxic effects of the drug itself, drug impurities, and nonsterile injection. The abdominal radiologist is likely to encounter patients who use drugs recreationally and may be responsible for recognizing and reporting these acute conditions, which in some cases can be life threatening. Because these patients often present with an altered mental state and may deny or withhold information on drug use, the underlying cause may be difficult to determine. The most commonly used drugs worldwide include cocaine, cannabinoids, opioids, and amphetamines and their derivatives. Complications of use of these drugs that can be seen at abdominopelvic CT can involve multiple organ systems, including the soft tissue and gastrointestinal, genitourinary, vascular, and musculoskeletal systems. A diverse range of abdominal complications associated with these drugs can be seen at imaging, including disseminated infections, gastrointestinal ischemia, and visceral infarction. Radiologists should be familiar with the imaging findings of these complications to accurately diagnose these entities and help guide workup and patient treatment. ©RSNA, 2020.
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Affiliation(s)
- Joseph Mansour
- From the Department of Radiology, Saint Louis University Hospital, 3635 Vista Ave, 2nd Floor, Deslodge Tower, St Louis, MO 63103-2097 (J.M., A.U.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (J.M., M.Z.); Department of Radiology, Mayo Clinic, Scottsdale, Ariz (K.S.Z., C.O.M.); and Department of Radiology, Massachusetts General Hospital, Boston, Mass (A.H.)
| | - Maria Zulfiqar
- From the Department of Radiology, Saint Louis University Hospital, 3635 Vista Ave, 2nd Floor, Deslodge Tower, St Louis, MO 63103-2097 (J.M., A.U.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (J.M., M.Z.); Department of Radiology, Mayo Clinic, Scottsdale, Ariz (K.S.Z., C.O.M.); and Department of Radiology, Massachusetts General Hospital, Boston, Mass (A.H.)
| | - Affan Umer
- From the Department of Radiology, Saint Louis University Hospital, 3635 Vista Ave, 2nd Floor, Deslodge Tower, St Louis, MO 63103-2097 (J.M., A.U.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (J.M., M.Z.); Department of Radiology, Mayo Clinic, Scottsdale, Ariz (K.S.Z., C.O.M.); and Department of Radiology, Massachusetts General Hospital, Boston, Mass (A.H.)
| | - Kenneth S Zurcher
- From the Department of Radiology, Saint Louis University Hospital, 3635 Vista Ave, 2nd Floor, Deslodge Tower, St Louis, MO 63103-2097 (J.M., A.U.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (J.M., M.Z.); Department of Radiology, Mayo Clinic, Scottsdale, Ariz (K.S.Z., C.O.M.); and Department of Radiology, Massachusetts General Hospital, Boston, Mass (A.H.)
| | - Allen Heeger
- From the Department of Radiology, Saint Louis University Hospital, 3635 Vista Ave, 2nd Floor, Deslodge Tower, St Louis, MO 63103-2097 (J.M., A.U.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (J.M., M.Z.); Department of Radiology, Mayo Clinic, Scottsdale, Ariz (K.S.Z., C.O.M.); and Department of Radiology, Massachusetts General Hospital, Boston, Mass (A.H.)
| | - Christine O Menias
- From the Department of Radiology, Saint Louis University Hospital, 3635 Vista Ave, 2nd Floor, Deslodge Tower, St Louis, MO 63103-2097 (J.M., A.U.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (J.M., M.Z.); Department of Radiology, Mayo Clinic, Scottsdale, Ariz (K.S.Z., C.O.M.); and Department of Radiology, Massachusetts General Hospital, Boston, Mass (A.H.)
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Al-Horani RA, Kar S. Potential Anti-SARS-CoV-2 Therapeutics That Target the Post-Entry Stages of the Viral Life Cycle: A Comprehensive Review. Viruses 2020; 12:E1092. [PMID: 32993173 PMCID: PMC7600245 DOI: 10.3390/v12101092] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/08/2020] [Accepted: 09/23/2020] [Indexed: 02/06/2023] Open
Abstract
The coronavirus disease-2019 (COVID-19) pandemic continues to challenge health care systems around the world. Scientists and pharmaceutical companies have promptly responded by advancing potential therapeutics into clinical trials at an exponential rate. Initial encouraging results have been realized using remdesivir and dexamethasone. Yet, the research continues so as to identify better clinically relevant therapeutics that act either as prophylactics to prevent the infection or as treatments to limit the severity of COVID-19 and substantially decrease the mortality rate. Previously, we reviewed the potential therapeutics in clinical trials that block the early stage of the viral life cycle. In this review, we summarize potential anti-COVID-19 therapeutics that block/inhibit the post-entry stages of the viral life cycle. The review presents not only the chemical structures and mechanisms of the potential therapeutics under clinical investigation, i.e., listed in clinicaltrials.gov, but it also describes the relevant results of clinical trials. Their anti-inflammatory/immune-modulatory effects are also described. The reviewed therapeutics include small molecules, polypeptides, and monoclonal antibodies. At the molecular level, the therapeutics target viral proteins or processes that facilitate the post-entry stages of the viral infection. Frequent targets are the viral RNA-dependent RNA polymerase (RdRp) and the viral proteases such as papain-like protease (PLpro) and main protease (Mpro). Overall, we aim at presenting up-to-date details of anti-COVID-19 therapeutics so as to catalyze their potential effective use in fighting the pandemic.
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Affiliation(s)
- Rami A. Al-Horani
- Division of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans, LA 70125, USA;
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George JT, Janeela AM, Sigamani E, Mathuram AJ. A fatal case of levamisole induced bone marrow failure. BMJ Case Rep 2019; 12:12/9/e231167. [PMID: 31570359 DOI: 10.1136/bcr-2019-231167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
A 20-year-old college student presented with high grade, intermittent fever for 10 days associated with blood stained loose stools after taking tablet levamisole for 17 days for vitiligo vulgaris. He was febrile, had a toxic appearance and appeared pale. Investigations showed neutropaenia with thrombocytopaenia. Blood cultures were sterile and stool cultures did not grow any enteric pathogens. His bone marrow examination was suggestive of an aplastic anaemia. He was administered empirical antibiotics, granulocyte colony stimulating factor and platelet transfusions. However, his fever and blood stained stools persisted. A repeat bone marrow examination after 2 weeks still revealed a hypoplastic marrow. Hence, a diagnosis of a levamisole induced bone marrow failure was made. While being worked up for an allogeneic stem cell transplantation, he developed neutropaenic enterocolitis and refractory septic shock with carbapenem resistant Klebsiella pneumoniae and succumbed to his illness.
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Affiliation(s)
- John Titus George
- Department of General Medicine, Christian Medical College and Hospital Vellore, Vellore, India
| | - Asisha M Janeela
- Department of General Medicine, Christian Medical College and Hospital Vellore, Vellore, India
| | - Elanthenral Sigamani
- Department of Pathology, Christian Medical College and Hospital Vellore, Vellore, India
| | - Alice Joan Mathuram
- Department of General Medicine, Christian Medical College and Hospital Vellore, Vellore, India
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Abstract
Levamisole is a veterinary antihelminthic, chemotherapeutic agent, and immunomodulator that also is used as an adulterant and cutting agent in cocaine distribution. This drug may potentiate the sympathomimetic actions of cocaine and can cause neutropenia, agranulocytosis, purpuric retiform lesions, and skin necrosis. This article describes two cases of suspected levamisole-induced vasculitis. No standardized diagnostic or treatment algorithm exists for this challenging condition. Diagnosis and treatment require a multidisciplinary team approach.
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Hammond BB, Craven J. Levamisole-Adulterated Cocaine Leading to Fatal Vasculitis: A Case Report. Crit Care Nurse 2018; 37:49-57. [PMID: 28765354 DOI: 10.4037/ccn2017977] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Cocaine is often "cut" with various additives to increase the profitability of the drug. One of the most common additives on today's market is levamisole, an anthelmintic medication used to destroy and expel parasitic worms in animals. The use of levamisole-contaminated cocaine can result in agranulocytosis and vasculitis (inflammation and constriction of small blood vessels). The resulting clotting and decrease in peripheral blood flow lead to cutaneous lesions, particularly on the ears, face, hands, and feet, and in severe cases can cause generalized tissue necrosis throughout the entire body. Treatment is generally supportive, and symptoms typically abate with complete cessation of cocaine use. However, symptoms may recur with subsequent cocaine use and, as this case illustrates, severe neutropenia and extensive vasculitis may lead to overwhelming sepsis and death.
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Affiliation(s)
- Belinda B Hammond
- Belinda B. Hammond is the critical care clinical nurse educator and coordinator of the new graduate Academy for Critical Care Nursing at Cone Health, Greensboro, North Carolina. .,Jordan Craven is a registered nurse in the cardiac ICU, Novant Health Forsyth Medical Center, Winston Salem, North Carolina.
| | - Jordan Craven
- Belinda B. Hammond is the critical care clinical nurse educator and coordinator of the new graduate Academy for Critical Care Nursing at Cone Health, Greensboro, North Carolina.,Jordan Craven is a registered nurse in the cardiac ICU, Novant Health Forsyth Medical Center, Winston Salem, North Carolina
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8
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A Case of Levamisole-Induced Agranulocytosis. Case Rep Hematol 2018; 2018:7341835. [PMID: 29607229 PMCID: PMC5828115 DOI: 10.1155/2018/7341835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 01/02/2018] [Indexed: 11/18/2022] Open
Abstract
A sixty-eight-year-old male with a past medical history of recurrent cocaine use presented to the emergency department with recurrent diarrhea and was found to have a white blood cell (WBC) count of 1.9 × 109/L with agranulocytosis (absolute neutrophil count (ANC) of 95 cell/mm3). At admission, the patient disclosed that he used cocaine earlier during the day, and a urine drug screen tested positive for this. On hospital day one, the patient was found to have a fever with a maximum temperature of 313.6 K. After ruling out other causes and noting the quick turnaround of his neutropenia after four days of cocaine abstinence, the patient's neutropenia was attributed to levamisole-adulterated cocaine.
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Mokarram P, Albokashy M, Zarghooni M, Moosavi MA, Sepehri Z, Chen QM, Hudecki A, Sargazi A, Alizadeh J, Moghadam AR, Hashemi M, Movassagh H, Klonisch T, Owji AA, Łos MJ, Ghavami S. New frontiers in the treatment of colorectal cancer: Autophagy and the unfolded protein response as promising targets. Autophagy 2017; 13:781-819. [PMID: 28358273 PMCID: PMC5446063 DOI: 10.1080/15548627.2017.1290751] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Colorectal cancer (CRC), despite numerous therapeutic and screening attempts, still remains a major life-threatening malignancy. CRC etiology entails both genetic and environmental factors. Macroautophagy/autophagy and the unfolded protein response (UPR) are fundamental mechanisms involved in the regulation of cellular responses to environmental and genetic stresses. Both pathways are interconnected and regulate cellular responses to apoptotic stimuli. In this review, we address the epidemiology and risk factors of CRC, including genetic mutations leading to the occurrence of the disease. Next, we discuss mutations of genes related to autophagy and the UPR in CRC. Then, we discuss how autophagy and the UPR are involved in the regulation of CRC and how they associate with obesity and inflammatory responses in CRC. Finally, we provide perspectives for the modulation of autophagy and the UPR as new therapeutic options for CRC treatment.
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Affiliation(s)
- Pooneh Mokarram
- a Colorectal Research Center and Department of Biochemistry , School of Medicine, Shiraz University of Medical Sciences , Shiraz , Iran
| | - Mohammed Albokashy
- b Department of Human Anatomy and Cell Science , Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba , Winnipeg , MB , Canada
| | - Maryam Zarghooni
- c Zabol University of Medical Sciences , Zabol , Iran.,d University of Toronto Alumni , Toronto , ON , Canada
| | - Mohammad Amin Moosavi
- e Department of Molecular Medicine , Institute of Medical Biotechnology, National Institute for Genetic Engineering and Biotechnology , Tehran , Iran
| | - Zahra Sepehri
- c Zabol University of Medical Sciences , Zabol , Iran
| | - Qi Min Chen
- b Department of Human Anatomy and Cell Science , Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba , Winnipeg , MB , Canada
| | | | | | - Javad Alizadeh
- b Department of Human Anatomy and Cell Science , Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba , Winnipeg , MB , Canada
| | - Adel Rezaei Moghadam
- b Department of Human Anatomy and Cell Science , Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba , Winnipeg , MB , Canada
| | - Mohammad Hashemi
- g Department of Clinical Biochemistry , School of Medicine, Zahedan University of Medical Sciences , Zahedan , Iran
| | - Hesam Movassagh
- h Department of Immunology , Rady Faculty of Health Sciences, College of Medicine, University of Manitoba , Winnipeg , MB , Canada
| | - Thomas Klonisch
- b Department of Human Anatomy and Cell Science , Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba , Winnipeg , MB , Canada
| | - Ali Akbar Owji
- i Department of Clinical Biochemistry , School of Medicine, Shiraz Medical University , Shiraz , Iran
| | - Marek J Łos
- j Małopolska Centre of Biotechnology , Jagiellonian University , Krakow , Poland ; LinkoCare Life Sciences AB , Sweden
| | - Saeid Ghavami
- b Department of Human Anatomy and Cell Science , Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba , Winnipeg , MB , Canada.,k Health Policy Research Center , Shiraz University of Medical Sciences , Shiraz , Iran
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Levamisole-adulterated cocaine: Two fatal case reports and evaluation of possible cocaine toxicity potentiation. Forensic Sci Int 2016; 265:103-6. [DOI: 10.1016/j.forsciint.2016.01.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 12/30/2015] [Accepted: 01/02/2016] [Indexed: 12/28/2022]
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Abstract
Agranulocytosis is a rare complication of levamisole. We report a 22-year-old female who developed agranulocytosis due to levamisole. The patient initially presented with salmonellosis and agranulocytosis, and then she recovered with treatment. However, 2 months after discharge, she again presented with tonsillitis and agranulocytosis. This time the family revealed that she had been taking levamisole. Though Salmonella infection is a recognized cause of agranulocytosis, any patient presenting with repeated agranulocytosis after an initial recovery should make the clinician suspect another cause, especially drug-induced. A case of Salmonella infection where levamisole was an unsuspecting cause of agranulocytosis has not been described in indexed literature. Recurrent agranulocytosis due to repeated exposure to levamisole has also not been described.
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Affiliation(s)
- Abraham M Ittyachen
- Department of Medicine, Malankara Orthodox Syrian Church Medical College, Kolenchery, Ernakulam District, Kerala, India
| | - Mohan B Jose
- Department of Medicine, Malankara Orthodox Syrian Church Medical College, Kolenchery, Ernakulam District, Kerala, India
| | - Jobin R Benjamin
- Department of Medicine, Malankara Orthodox Syrian Church Medical College, Kolenchery, Ernakulam District, Kerala, India
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Nowak LG, Rosay B, Czégé D, Fonta C. Tetramisole and Levamisole Suppress Neuronal Activity Independently from Their Inhibitory Action on Tissue Non-specific Alkaline Phosphatase in Mouse Cortex. Subcell Biochem 2015. [PMID: 26219715 DOI: 10.1007/978-94-017-7197-9_12] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Tissue non-specific alkaline phosphatase (TNAP) may be involved in the synthesis of GABA and adenosine, which are the main inhibitory neurotransmitters in cortex. We explored this putative TNAP function through electrophysiological recording (local field potential ) in slices of mouse somatosensory cortex maintained in vitro. We used tetramisole, a well documented TNAP inhibitor, to block TNAP activity. We expected that inhibiting TNAP with tetramisole would lead to an increase of neuronal response amplitude, owing to a diminished availability of GABA and/or adenosine. Instead, we found that tetramisole reduced neuronal response amplitude in a dose-dependent manner. Tetramisole also decreased axonal conduction velocity. Levamisole had identical effects. Several control experiments demonstrated that these actions of tetramisole were independent from this compound acting on TNAP. In particular, tetramisole effects were not stereo-specific and they were not mimicked by another inhibitor of TNAP, MLS-0038949. The decrease of axonal conduction velocity and preliminary intracellular data suggest that tetramisole blocks voltage-dependent sodium channels. Our results imply that levamisole or tetramisole should not be used with the sole purpose of inhibiting TNAP in living excitable cells as it will also block all processes that are activity-dependent. Our data and a review of the literature indicate that tetramisole may have at least four different targets in the nervous system. We discuss these results with respect to the neurological side effects that were observed when levamisole and tetramisole were used for medical purposes, and that may recur nowadays due to the recent use of levamisole and tetramisole as cocaine adulterants.
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Affiliation(s)
- Lionel G Nowak
- Centre de Recherche Cerveau et Cognition (CerCo), Université de Toulouse UPS; CNRS UMR 5549 , Toulouse, France,
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A Direct Immersion Solid-Phase Microextraction Gas Chromatography/Mass Spectrometry Method for the Simultaneous Detection of Levamisole and Minor Cocaine Congeners in Hair Samples From Chronic Abusers. Ther Drug Monit 2014; 36:789-95. [DOI: 10.1097/ftd.0000000000000076] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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14
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Determination of levamisole and tetramisole in seized cocaine samples by enantioselective high-performance liquid chromatography and circular dichroism detection. J Chromatogr A 2014; 1363:150-4. [DOI: 10.1016/j.chroma.2014.07.069] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 07/11/2014] [Accepted: 07/22/2014] [Indexed: 11/19/2022]
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Affiliation(s)
- D Ananthan
- From the SUNY Upstate Medical University, Syracuse, NY, USA
| | - S Shah
- From the SUNY Upstate Medical University, Syracuse, NY, USA
| | - H H Koya
- From the SUNY Upstate Medical University, Syracuse, NY, USA
| | - A Patel
- From the SUNY Upstate Medical University, Syracuse, NY, USA
| | - S Graziano
- From the SUNY Upstate Medical University, Syracuse, NY, USA
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Trojan horses: drug culprits associated with antineutrophil cytoplasmic autoantibody (ANCA) vasculitis. Curr Opin Rheumatol 2014; 26:42-9. [PMID: 24276086 DOI: 10.1097/bor.0000000000000014] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Antineutrophil cytoplasmic autoantibody (ANCA) vasculitis is a systemic autoimmune disease resulting in small-vessel inflammation caused by pathogenic autoantibodies directed against proteinase 3 or myeloperoxidase. Legal drug culprits have been implicated as causative agents in secondary forms of disease, and a recent burst of reports also implicate levamisole-adulterated cocaine as a culprit. RECENT FINDINGS Here, we briefly discuss all drug culprits associated with ANCA vasculitis and then focus on clinical, serologic, therapeutic and mechanistic aspects of four main drug culprits receiving attention of late, namely hydralazine, minocycline, propylthiouracil (PTU) and levamisole-adulterated cocaine. SUMMARY Hydralazine, minocycline, propylthiouracil and levamisole-adulterated cocaine use should be closely considered in any patient where ANCA vasculitis is entertained given the wide use of these drugs in the community. Furthermore, medical practitioners should test urine for the presence of cocaine in any patient with presumed ANCA vasculitis, and if positive, then urine should also be tested for levamisole. Clinical features can be severe requiring not only drug cessation and supportive care, but also immunosuppression, plasma exchange in severe cases and dialysis as needed. Clinical trial investigators should strongly consider excluding patients with drug-induced forms of disease and mechanistic inroads are greatly needed in these secondary forms of disease to help elucidate the underlying cause and pathogenesis of ANCA vasculitis.
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Hess C, Ritke N, Sydow K, Mehling LM, Ruehs H, Madea B, Musshoff F. Determination of levamisole, aminorex, and pemoline in plasma by means of liquid chromatography-mass spectrometry and application to a pharmacokinetic study of levamisole. Drug Test Anal 2014; 6:1049-54. [DOI: 10.1002/dta.1619] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 01/14/2014] [Accepted: 01/15/2014] [Indexed: 11/07/2022]
Affiliation(s)
- Cornelius Hess
- Institute of Forensic Medicine; University of Bonn; Stiftsplatz 12 D-53111 Bonn Germany
| | - Natalie Ritke
- Institute of Forensic Medicine; University of Bonn; Stiftsplatz 12 D-53111 Bonn Germany
| | - Konrad Sydow
- Institute of Forensic Medicine; University of Bonn; Stiftsplatz 12 D-53111 Bonn Germany
| | - Lena-Maria Mehling
- Institute of Forensic Medicine; University of Bonn; Stiftsplatz 12 D-53111 Bonn Germany
| | - Hauke Ruehs
- Institute of Clinical Pharmacy; University of Bonn; An der Immenburg 4 D-53121 Bonn Germany
| | - Burkhard Madea
- Institute of Forensic Medicine; University of Bonn; Stiftsplatz 12 D-53111 Bonn Germany
| | - Frank Musshoff
- Institute of Forensic Medicine; University of Bonn; Stiftsplatz 12 D-53111 Bonn Germany
- Forensic Toxicological Centre (FTC); Bayerstr. 53 D-80335 Munich Germany
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Lemaignen A, Goulenok T, Kalamarides S, Plat A, Pfau G, Fantin B. [Agranulocytosis and vasculitis in a cocaine addict: levamisole, the hidden culprit]. Rev Med Interne 2013; 35:676-9. [PMID: 24290029 DOI: 10.1016/j.revmed.2013.10.337] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Accepted: 10/24/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Adulterants are compounds added to street drugs to increase profits for the seller. Levamisole, a veterinary antihelminthic agent, has become the most common adulterant of cocaine. The prevalence of levamisole in samples of cocaine is increasing. Levamisole can lead to neutropenia and to a dramatic vasculopathy and even vasculitis of small and medium-size blood vessels. CASE REPORT We here reported the first French case of levamisole related toxicity, due to cocaine use in a 50-year-old man, revealed by fever and agranulocytosis, high titters of antineutrophil cytoplasmic antibodies (ANCA), anticoagulant and positive Coombs tests. Outcome was slowly favorable with exposition withdrawal. CONCLUSION Clinicians should be aware that agranulocytosis or vasculitis or vasculopathy could be related to levamisole toxicity in individuals who use cocaine.
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Affiliation(s)
- A Lemaignen
- Service de médecine interne, hôpital Beaujon, université Paris Diderot, Sorbonne Paris-Cité, AP-HP, 100, boulevard du Général-Leclerc, 92110 Clichy, France
| | - T Goulenok
- Service de médecine interne, hôpital Beaujon, université Paris Diderot, Sorbonne Paris-Cité, AP-HP, 100, boulevard du Général-Leclerc, 92110 Clichy, France.
| | - S Kalamarides
- Unité de traitement ambulatoire des maladies addictives (UTAMA), hôpital Beaujon, université Paris Diderot, Sorbonne Paris-Cité, AP-HP, 100, boulevard du Général-Leclerc, 92110 Clichy, France
| | - A Plat
- Unité de traitement ambulatoire des maladies addictives (UTAMA), hôpital Beaujon, université Paris Diderot, Sorbonne Paris-Cité, AP-HP, 100, boulevard du Général-Leclerc, 92110 Clichy, France
| | - G Pfau
- Dispositif TREND/SINTES Paris, association Charonne, 75012 Paris, France
| | - B Fantin
- Service de médecine interne, hôpital Beaujon, université Paris Diderot, Sorbonne Paris-Cité, AP-HP, 100, boulevard du Général-Leclerc, 92110 Clichy, France
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Hofmaier T, Luf A, Seddik A, Stockner T, Holy M, Freissmuth M, Ecker GF, Schmid R, Sitte HH, Kudlacek O. Aminorex, a metabolite of the cocaine adulterant levamisole, exerts amphetamine like actions at monoamine transporters. Neurochem Int 2013; 73:32-41. [PMID: 24296074 PMCID: PMC4077236 DOI: 10.1016/j.neuint.2013.11.010] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 11/22/2013] [Accepted: 11/24/2013] [Indexed: 11/17/2022]
Abstract
We quantified adulterants in street drugs sold as cocaine. We analyzed effects of the most common adulterant levamisole, on neurotransmitter transporters. Differences in the selectivity of levamisole can be explained by homology modelling and docking. Aminorex, a metabolite of levamisole, modulates neurotransmitter transporters directly. Depending on the transporter, aminorex acts as a blocker or as a releaser.
Psychostimulants such as amphetamine and cocaine are illicitly used drugs that act on neurotransmitter transporters for dopamine, serotonin or norepinephrine. These drugs can by themselves already cause severe neurotoxicity. However, an additional health threat arises from adulterant substances which are added to the illicit compound without declaration. One of the most frequently added adulterants in street drugs sold as cocaine is the anthelmintic drug levamisole. We tested the effects of levamisole on neurotransmitter transporters heterologously expressed in HEK293 cells. Levamisole was 100 and 300-fold less potent than cocaine in blocking norepinephrine and dopamine uptake, and had only very low affinity for the serotonin transporter. In addition, levamisole did not trigger any appreciable substrate efflux. Because levamisole and cocaine are frequently co-administered, we searched for possible allosteric effects; at 30 μM, a concentration at which levamisole displayed already mild effects on norepinephrine transport it did not enhance the inhibitory action of cocaine. Levamisole is metabolized to aminorex, a formerly marketed anorectic drug, which is classified as an amphetamine-like substance. We examined the uptake-inhibitory and efflux-eliciting properties of aminorex and found it to exert strong effects on all three neurotransmitter transporters in a manner similar to amphetamine. We therefore conclude that while the adulterant levamisole itself has only moderate effects on neurotransmitter transporters, its metabolite aminorex may exert distinct psychostimulant effects by itself. Given that the half-time of levamisole and aminorex exceeds that of cocaine, it may be safe to conclude that after the cocaine effect “fades out” the levamisole/aminorex effect “kicks in”.
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Affiliation(s)
- Tina Hofmaier
- Institute of Pharmacology, Center for Physiology and Pharmacology, Medical University of Vienna, Waehringerstrasse 13A, 1090 Vienna, Austria
| | - Anton Luf
- Clinical Department of Laboratory Medicine, Medical University of Vienna, Waehringer Guertel 10-20, 1090 Vienna, Austria
| | - Amir Seddik
- University of Vienna, Department of Medicinal Chemistry, Althanstrasse 14, 1090 Vienna, Austria
| | - Thomas Stockner
- Institute of Pharmacology, Center for Physiology and Pharmacology, Medical University of Vienna, Waehringerstrasse 13A, 1090 Vienna, Austria
| | - Marion Holy
- Institute of Pharmacology, Center for Physiology and Pharmacology, Medical University of Vienna, Waehringerstrasse 13A, 1090 Vienna, Austria
| | - Michael Freissmuth
- Institute of Pharmacology, Center for Physiology and Pharmacology, Medical University of Vienna, Waehringerstrasse 13A, 1090 Vienna, Austria
| | - Gerhard F Ecker
- University of Vienna, Department of Medicinal Chemistry, Althanstrasse 14, 1090 Vienna, Austria
| | - Rainer Schmid
- Clinical Department of Laboratory Medicine, Medical University of Vienna, Waehringer Guertel 10-20, 1090 Vienna, Austria
| | - Harald H Sitte
- Institute of Pharmacology, Center for Physiology and Pharmacology, Medical University of Vienna, Waehringerstrasse 13A, 1090 Vienna, Austria.
| | - Oliver Kudlacek
- Institute of Pharmacology, Center for Physiology and Pharmacology, Medical University of Vienna, Waehringerstrasse 13A, 1090 Vienna, Austria
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Abstract
Cocaine-induced leukoencephalopathy is a rare neurological complication. It is most likely related to the substances used to adulterate the cocaine. Levamisole is one of the most common adulterants of cocaine and causes reversible leukoencephalopathy. Patients display severe neurological symptoms that resolve at termination of the exposure. MRI shows diffuse white matter involvement with sparing of the U fibers, without brain stem or cerebellar involvement. We describe the case of a woman with three neurologic episodes and remitting and recurrent brain white matter lesions.
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Affiliation(s)
- Alejandra González-Duarte
- Departments of Neurology, Salvador Zubirán National Institute of Medical Sciences and Nutrition; Mexico City, Mexico -
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González-Duarte A, Williams R. Cocaine-induced recurrent leukoencephalopathy. Neuroradiol J 2013; 26:511-3. [PMID: 24199810 DOI: 10.1177/197140091302600503] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 10/04/2013] [Indexed: 11/17/2022] Open
Abstract
Cocaine-induced leukoencephalopathy is a rare neurological complication. It is most likely related to the substances used to adulterate the cocaine. Levamisole is one of the most common adulterants of cocaine and causes reversible leukoencephalopathy. Patients display severe neurological symptoms that resolve at termination of the exposure. MRI shows diffuse white matter involvement with sparing of the U fibers, without brain stem or cerebellar involvement. We describe the case of a woman with three neurologic episodes and remitting and recurrent brain white matter lesions.
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Affiliation(s)
- Alejandra González-Duarte
- Departments of Neurology, Salvador Zubirán National Institute of Medical Sciences and Nutrition; Mexico City, Mexico -
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Auffenberg C, Rosenthal LJ, Dresner N. Levamisole: A Common Cocaine Adulterant with Life-Threatening Side Effects. PSYCHOSOMATICS 2013; 54:590-3. [DOI: 10.1016/j.psym.2013.02.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2012] [Revised: 02/19/2013] [Accepted: 02/20/2013] [Indexed: 10/26/2022]
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Abstract
Levamisole-contaminated cocaine has recently been recognized in North America and Europe, and its use is associated with a variety of clinical and autoimmune abnormalities. The clinical characteristic seems to be the presence of a painful purpuric skin rash that predominantly affects the ear lobes and cheeks, often accompanied by systemic manifestations including fever, malaise, arthralgias, myalgias, and laboratory abnormalities, for example leukopenia, neutropenia, positive ANA, ANCA, and phospholipid antibodies. Most of these manifestations can be seen with the use of either drug, especially levamisole. There is no specific therapy, and discontinuation of its use is followed by improvement. Prednisone and immunosuppressive therapy may be needed at times. Further use of the drug is characterized by recurrence of most of the complaints.
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Hess C, Ritke N, Broecker S, Madea B, Musshoff F. Metabolism of levamisole and kinetics of levamisole and aminorex in urine by means of LC-QTOF-HRMS and LC-QqQ-MS. Anal Bioanal Chem 2013; 405:4077-88. [DOI: 10.1007/s00216-013-6829-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Revised: 01/31/2013] [Accepted: 02/07/2013] [Indexed: 11/28/2022]
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Magliocca KR, Coker NA, Parker SR. The head, neck, and systemic manifestations of levamisole-adulterated cocaine use. J Oral Maxillofac Surg 2013; 71:487-92. [PMID: 23298805 DOI: 10.1016/j.joms.2012.10.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 10/29/2012] [Indexed: 11/26/2022]
Abstract
Systemic complications of levamisole-adulterated cocaine (LAC) use have recently been described. The objective of this review is to increase awareness of these manifestations among oral and maxillofacial surgeons. LAC exposure through inhalation, nasal insufflation, or injection can induce cutaneous vasculopathy and hematologic abnormalities such as neutropenia or agranulocytosis. Unlike other vasculopathies involving the skin, LAC-induced vascular injury frequently manifests with purpuric and necrotic lesions that involve the face and ears. Oral manifestations have also been reported but are not yet well characterized. The aforementioned hematologic manifestations are not uncommon, and patients exposed to LAC are potentially at higher risk for infectious complications. When manifestations of LAC affect the head, neck, and oral cavity, oral and maxillofacial surgeons may be the first providers to encounter the patient. Early recognition of the clinical signs and laboratory abnormalities will better allow for distinguishing LAC-related effects from various clinical mimics, will facilitate appropriate patient management, and may further contribute to the understanding of the biological effects of LAC.
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Affiliation(s)
- Kelly R Magliocca
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA 30322, USA.
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Blanc PD, Chin C, Lynch KL. Multifocal inflammatory leukoencephalopathy associated with cocaine abuse: Is levamisole responsible? Clin Toxicol (Phila) 2012; 50:534-5; author reply 536. [DOI: 10.3109/15563650.2012.692794] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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