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El Abass SA, Wahba MEK, Draz ME. A green, fluorescent probe employing erythrosine-B for tracing the accidental administration of levamisole in milk and plasma samples. ANALYTICAL METHODS : ADVANCING METHODS AND APPLICATIONS 2024; 16:4856-4864. [PMID: 38967542 DOI: 10.1039/d4ay00878b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
A simple and sensitive fluorescent probe has been developed and optimized to detect the non-intentional administration of levamisole (LVM). LVM is used as an anthelmintic therapy in cows, and hence, its residues appear in the drained milk until 60 hours after administering the drug. Meanwhile, levamisole is known to be an adulterant to cocaine and could be detected in addicts' plasma samples. Owing to its severe side effects, including agranulocytosis, which is lethal in many cases, detection and quantification of LVM in milk and plasma samples are of utmost importance. Therefore, a sensitive and selective analytical method is required for this purpose. This work develops a highly fluorescent probe obtained through the reaction between LVM and erythrosine-B in an acidic medium, where the produced ion pair complex has been measured at 553 nm after excitation at 528 nm. The proposed method provides linearity over the concentration range of 0.5-2.0 μg mL-1 for LVM, with a corresponding detection and quantitation limit of 0.5 and 0.3 μg mL-1. Full validation was performed, permitting the application of the suggested method to perform simple extraction steps. All the applied procedures followed the guidelines offered by green analytical chemistry, where the Green Analytical Procedure Index (GAPI) assessed the greenness of the proposed tool, and the yielded pictograms proved the eco-friendliness of the offered tool.
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Affiliation(s)
- Samah Abo El Abass
- Pharmaceutical Chemistry Department, College of Pharmacy, Prince Sattam Bin-Abdul Aziz University, PO Box 173, Al-Kharj 11942, Kingdom of Saudi Arabia.
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, Mansoura University, Mansoura 35516, Egypt
| | - May E K Wahba
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, Mansoura University, Mansoura 35516, Egypt
- Pharmaceutical Chemistry Department, Faculty of Pharmacy, Delta University for Science and Technology, Gamasa, Egypt
| | - Mohammed E Draz
- Pharmaceutical Chemistry Department, Faculty of Pharmacy, Delta University for Science and Technology, Gamasa, Egypt
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Osorio M, Velásquez I, Vargas R, Vanegas-García A, Rojas M, Vásquez G, Muñoz-Vahos C. NETosis Secondary to the Use of Levamisole-Adulterated Cocaine: A Likely Underlying Mechanism of Vasculopathy. J Toxicol 2024; 2024:7388799. [PMID: 38434602 PMCID: PMC10904679 DOI: 10.1155/2024/7388799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 01/31/2024] [Accepted: 02/09/2024] [Indexed: 03/05/2024] Open
Abstract
Background Since 2010, several cases of a new vasculopathy induced by the use of levamisole-adulterated cocaine (LAC) have been reported. This vasculopathy is characterized by retiform purpura, earlobe necrosis, multisystem compromise, and multiple autoantibodies. Given its similarity to antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, LAC-associated vasculopathy is postulated to be mediated by pathophysiologic processes resulting from neutrophil cell death by NETosis, a phenomenon previously described in ANCA vasculitis. This study tries to establish the presence of NETosis induced by cocaine, levamisole, or both. Methodology. Neutrophils were isolated from the peripheral blood of healthy controls by Ficoll-Hystopaque density gradient centrifugation followed by dextran sedimentation. Cell viability and purity were evaluated by flow cytometry after staining with PI/DiOC6 and labeling with fluorescent anti-CD45/anti-CD3 monoclonal antibodies (mAbs), respectively. Neutrophils were exposed to levamisole, cocaine, a cocaine-levamisole mixture, and sera pools from healthy controls and patients with LAC-associated vasculopathy. NETosis was then assessed by flow cytometry after staining cells with Sytox Green, Hoechst-33342, and fluorescent antineutrophil elastase (NE) and antimyeloperoxidase (MPO) mAbs. In addition, NETosis was morphologically confirmed by fluorescence microscopy. Proinflammatory cytokine levels in culture supernatants and reactive oxygen species (ROS) synthesis were determined by flow cytometry. The involvement of calcium and muscarinic receptors in cell death induction was evaluated in parallel experiments carried out in the presence of 1,2-bis (o-aminophenoxy) ethane-N, N, N', N'-tetraacetic acid (BAPTA) and hyoscine butylbromide (HBB), their respective inhibitors. Results Cocaine, levamisole, and a cocaine-levamisole mixture induced neutrophil cell death. DNA/MPO extrusion and cell morphology patterns were consistent with NETosis. Neither proinflammatory cytokines nor ROS behaved as proNETotic factors. Preliminary results suggested that muscarinic receptors and calcium-dependent signals were involved in LAC-induced NETosis. Conclusions Cocaine, levamisole, and a cocaine-levamisole mixture can induce NETosis through mechanisms involving muscarinic receptors and calcium-dependent pathways.
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Affiliation(s)
- Manuela Osorio
- Grupo de Inmunología Celular e Inmunogenética, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | - Isabel Velásquez
- Grupo de Inmunología Celular e Inmunogenética, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | - Ruben Vargas
- Grupo de Inmunología Celular e Inmunogenética, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | - Adriana Vanegas-García
- Hospital Universitario San Vicente Fundación, Medellín, Colombia
- Sección de Reumatología, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | - Mauricio Rojas
- Grupo de Inmunología Celular e Inmunogenética, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | - Gloria Vásquez
- Grupo de Inmunología Celular e Inmunogenética, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | - Carlos Muñoz-Vahos
- Hospital Universitario San Vicente Fundación, Medellín, Colombia
- Sección de Reumatología, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
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Assi S, Keenan A, Al Hamid A. Exploring e-psychonauts perspectives towards cocaine effects and toxicity. Subst Abuse Treat Prev Policy 2022; 17:48. [PMID: 35761409 PMCID: PMC9238119 DOI: 10.1186/s13011-022-00455-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2022] [Indexed: 11/12/2022] Open
Abstract
Background According to the World Drug Report, cocaine is the second most used drug globally after cannabis. Online discussion forums enable the understanding of authentic drug users’ experience as it is anonymous. Therefore, this study determined the uses, effects and toxicity of cocaine from the perspectives’ of e-psychonauts. Methods A qualitative study was conducted using six popular discussion forums. From these discussion forums, 1229 posts from 50 threads were subject to thematic analysis. Hence, the information from these threads were examined carefully for patterns and codes among the data. The codes were then collated into subthemes and themes. Results The four main themes emerging from the study were related to cocaine characteristics and use, e-psychonauts’ knowledge and experience, desired effects and adverse events. The main characteristic associated with cocaine use was purity that was highest in the US being nearest to the source. The most common cutting agent encountered in cocaine samples was levamisole that increased the chances of immunosuppression and cardiovascular toxicity. Purity depended on the source of purchase that included street dealers, dark web and surface web. Hence, e-psychonauts recommended purchase of cocaine from known dealers rather than websites with unknown sources. E-psychonauts mainly used cocaine in social context and parties or to self-medicate against anxiety and depression. Effects desired from cocaine use were mainly euphoria and increased energy. However, tachycardia and myocardial infarction were the main adverse events. It is noteworthy to mention that myocardial infarction was idiosyncratic and was often lethal. Myocardial infarction was more often reported when cocaine was combined with alcohol due to the production of cocaethylene. Social harm was also reported as a consequence for the use of cocaine that resulted in homelessness and broken relationships. Conclusion Online discussion forums allowed the understanding of e-psychonauts’ experience with cocaine use. Not only it informed about the sources and modalities of use of cocaine but also about the adverse events and social harm associated with cocaine use. The present findings serve as useful information for practitioners and healthcare professionals dealing with cocaine users.
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Fang L, Nikfarjam N, Gharagozlou M, Huang T, Song Y, Islambulchilar Z, Esmaeilzadeh A, Jafari D, Athari SS. Pulmonary Delivery of Levamisole Nanoparticles as an Immunomodulator Affecting Th and a Potential ADAM10 Inhibitor to Ameliorate Severe Allergic Asthma. ACS Biomater Sci Eng 2022; 8:4566-4576. [PMID: 36054652 DOI: 10.1021/acsbiomaterials.2c00843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Asthma is a common chronic lung disease without absolute treatment, and hypersensitivity reactions and type 2 immune responses are responsible for asthma pathophysiology. ADAM10 as a metalloproteinase transmembrane protein is critical for development of Th2 responses, and levamisole as an anthelmintic drug has immunomodulatory effects, which not only regulates ADAM10 activity but also can suppress the bone marrow and neutrophil production. Therefore, in the present study, nanoparticles were used as a levamisole delivery system to reduce bone marrow suppression, and the immunomodulatory and ADAM10 inhibitory effects of levamisole were studied in allergic asthma. Asthmatic mice were treated with PLGA-levamisole nanoparticles. Then, AHR, BALF, and blood cell counts, levels of the IgG1 subclass, total and OVA-specific IgE, IL2, IL-4, IL-5, IL-10, IL-13, IL-17, IL-25, IL-33, INF-γ, and TNF-α, gene expression of FoxP3, T-bet, RORγt, PU.1, GATA3, FcεRII, CysLT1R, eotaxin, and ADAM10, and lung histopathology were evaluated. PLGA-LMHCl with considered characteristics could control airway hyper-responsiveness, eosinophils in the BALF, levels of immunoglobulins, Th2-, Th9-, and Th17-derived cytokines and pivotal genes, eosinophilic inflammation, hyperplasia of the goblet cell, and hyperproduction of mucus and could increase Th1- and Treg-derived cytokines and also pivotal genes. It could also modulate the ADAM10 activity and had no effect on the number of neutrophils in the bloodstream. The novel safe nanodrug had no side effect on the bone marrow to produce neutrophils and could control the allegro-immuno-inflammatory response of asthma.
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Affiliation(s)
- Liping Fang
- Department of Respiratory and Critical Care Medicine, Xi'an People's Hospital (Xi'an Fourth Hospital), 155 East Aerospace Road, Xi'an 710100, Shaanxi, China
| | - Nasser Nikfarjam
- Department of Chemistry, Institute for Advanced Studies in Basic Sciences (IASBS), Zanjan 45137-66731, Iran
| | - Mohammad Gharagozlou
- Department of Pediatrics, School of Medicine, Children's Medical Center, Tehran University of Medical Sciences, Tehran 1416753955, Iran
| | - Tao Huang
- Department of Orthopedics, The First Affiliated Hospital of Xi'an Medical University, 48 West Fengho Road, Lianhu District, Xi'an 710000, Shaanxi, China
| | - Yu Song
- Department of Respiratory and Critical Care Medicine, Xi'an People's Hospital (Xi'an Fourth Hospital), 155 East Aerospace Road, Xi'an 710100, Shaanxi, China
| | - Ziba Islambulchilar
- Department of Pharmaceutics, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz 5166/15731, Iran
| | - Abdolreza Esmaeilzadeh
- Department of Immunology, School of Medicine, Zanjan University of Medical Sciences, Zanjan 45371-38111, Iran
| | - Davood Jafari
- Department of Immunology, School of Medicine, Zanjan University of Medical Sciences, Zanjan 45371-38111, Iran
| | - Seyyed Shamsadin Athari
- Department of Immunology, School of Medicine, Zanjan University of Medical Sciences, Zanjan 45371-38111, Iran
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Serinelli S, Bonaccorso L, Furnari C, Gitto L. Double Suicide Due to the Ingestion of Levamisole-Adulterated Cocaine: Case Report and Review of the Literature. Acad Forensic Pathol 2022; 12:23-30. [PMID: 35694007 PMCID: PMC9179001 DOI: 10.1177/19253621211065334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 11/02/2021] [Indexed: 12/15/2022]
Abstract
Suicide is a major public health issue and the risk of attempting and committing suicide increases with age. We present the case of an elderly couple who decided to commit suicide together by self-poisoning using levamisole-adulterated cocaine. The choice of committing a double suicide, the method selected (self-poisoning), the drug self-administered (cocaine), and the route of administration (ingestion) are events rarely encountered in the forensic pathology practice, especially not in combination. In this article, we will review the literature regarding the frequency and features of these methods of suicide. An overview of the effects and mechanism of action of levamisole is also provided, highlighting the importance of including this substance and its metabolites in the routine toxicological analyses for cocaine deaths.
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Affiliation(s)
- Serenella Serinelli
- Serenella Serinelli, MD, PhD, Department of Pathology, State University of New York–Upstate Medical University, 750 East Adams St. 13210, Syracuse, NY,
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Biggar E, Papamihali K, Leclerc P, Hyshka E, Graham B, Taylor M, Payer D, Maloney-Hall B, Buxton JA. Towards cross-Canada monitoring of the unregulated street drug supply. BMC Public Health 2021; 21:1678. [PMID: 34525994 PMCID: PMC8441944 DOI: 10.1186/s12889-021-11757-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 08/25/2021] [Indexed: 11/10/2022] Open
Abstract
Background The well-being of people who use drugs (PWUD) continues to be threatened by substances of unknown type or quantity in the unregulated street drug supply. Current efforts to monitor the drug supply are limited in population reach and comparability. This restricts capacity to identify and develop measures that safeguard the health of PWUD. This study describes the development of a low-barrier system for monitoring the contents of drugs in the unregulated street supply. Early results for pilot sites are presented and compared across regions. Methods The drug content monitoring system integrates a low-barrier survey and broad spectrum urine toxicology screening to compare substances expected to be consumed and those actually in the drug supply. The system prototype was developed by harm reduction pilot projects in British Columbia (BC) and Montreal with participation of PWUD. Data were collected from harm reduction supply distribution site clients in BC, Edmonton and Montreal between May 2018–March 2019. Survey and urine toxicology data were linked via anonymous codes and analyzed descriptively by region for trends in self-reported and detected use. Results The sample consisted of 878 participants from 40 sites across 3 regions. Reported use of substances, their detection, and concordance between the two varied across regions. Methamphetamine use was reported and detected most frequently in BC (reported: 62.8%; detected: 72.2%) and Edmonton (58.3%; 68.8%). In Montreal, high concordance was also observed between reported (74.5%) and detected (86.5%) cocaine/crack use. Among those with fentanyl detected, the percentage of participants who used fentanyl unintentionally ranged from 36.1% in BC, 78.6% in Edmonton and 90.9% in Montreal. Conclusions This study is the first to describe a feasible, scalable monitoring system for the unregulated drug supply that can contrast expected and actual drug use and compare trends across regions. The system used principles of flexibility, capacity-building and community participation in its design. Results are well-suited to meet the needs of PWUD and inform the local harm reduction services they rely on. Further standardization of the survey tool and knowledge mobilization is needed to expand the system to new jurisdictions.
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Affiliation(s)
- Emily Biggar
- Canadian Centre on Substance Use and Addiction, 500-75 Albert Street, Ottawa, ON, K1P 5E7, Canada.
| | - Kristi Papamihali
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Pascale Leclerc
- Direction régionale de santé publique, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal, 1301 rue Sherbrooke est, Montreal, QC, H2L 1M3, Canada
| | - Elaine Hyshka
- School of Public Health, University of Alberta, 3-300 Edmonton Clinic Health Academy, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Brittany Graham
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Marliss Taylor
- Streetworks, Boyle Street Community Services, 10116-105 Ave, Edmonton, Alberta, T5H 0K2, Canada
| | - Doris Payer
- Canadian Centre on Substance Use and Addiction, 500-75 Albert Street, Ottawa, ON, K1P 5E7, Canada
| | - Bridget Maloney-Hall
- Canadian Centre on Substance Use and Addiction, 500-75 Albert Street, Ottawa, ON, K1P 5E7, Canada
| | - Jane A Buxton
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada.,School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC, V6T 1Z3, Canada
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White CM, Browne T, Nafziger AN. Inherent Dangers of Using Non-US Food and Drug Administration-Approved Substances of Abuse. J Clin Pharmacol 2021; 61 Suppl 2:S129-S141. [PMID: 34396559 DOI: 10.1002/jcph.1860] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/17/2021] [Indexed: 12/25/2022]
Abstract
Use of US Food and Drug Administration-approved substances of abuse has innate risks due to pharmacologic and pharmacokinetic properties of the medications, but the risk when using nonapproved drug products is much greater. Unbeknownst to the user, the dose of active ingredients in substances of abuse can vary substantially between different products because of manufacturing practices or improper storage. Even naturally occurring substances of abuse can have extensive dosage variability because of effects of the growing season and conditions, or differences in harvesting, storage, or manufacture of the finished products. Many illicit substances are adulterated, to make up for intentional underdosing or to enhance the effect of the intended active ingredient. These adulterants can be dangerous and produce direct cardiovascular, neurologic, hematologic, or dermatologic reactions or obscure adverse effects. Finally, an illicit substance can be contaminated or substituted for another one during its manufacture, leading to differences in adverse events, adverse event severity, or the drug interaction profile. Substances can be contaminated with microbes that induce infections or heavy metals that can damage organs or cause cancer. This milieu of undisclosed substances can also induce drug interactions. For reasons that are discussed, individuals who use substances of abuse are at increased risk of morbidity or mortality if they develop coronavirus disease 2019. Health professionals who treat patients with acute, urgent events associated with substances of abuse, or those treating the chronic manifestations of addiction, need to appreciate the complex and variable composition of substances of abuse and their potential health effects.
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Affiliation(s)
- C Michael White
- Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA.,HOPES Research Group, UConn and Hartford Hospital, Hartford, Connecticut, USA
| | - Thom Browne
- Rubicon Global Enterprises & Colombo Plan Secretariat, Huachuca City, Arizona, USA
| | - Anne N Nafziger
- Bertino Consulting, Schenectady, New York, USA.,Department of Pharmacy Practice, School of Pharmacy & Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
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Identifying Cocaine Adulteration in the Unregulated Drug Supply in British Columbia, Canada. CANADIAN JOURNAL OF ADDICTION 2021. [DOI: 10.1097/cxa.0000000000000112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Fiorentin TR, Fogarty M, Limberger RP, Logan BK. Determination of cutting agents in seized cocaine samples using GC–MS, GC–TMS and LC–MS/MS. Forensic Sci Int 2019; 295:199-206. [DOI: 10.1016/j.forsciint.2018.12.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 12/14/2018] [Accepted: 12/18/2018] [Indexed: 10/27/2022]
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Fiorentin TR, Krotulski AJ, Martin DM, Browne T, Triplett J, Conti T, Logan BK. Detection of Cutting Agents in Drug‐Positive Seized Exhibits within the United States. J Forensic Sci 2018; 64:888-896. [DOI: 10.1111/1556-4029.13968] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 11/06/2018] [Accepted: 11/06/2018] [Indexed: 01/06/2023]
Affiliation(s)
- Taís R. Fiorentin
- The Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation 2300 Stratford Ave Willow Grove PA 19090
| | - Alex J. Krotulski
- The Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation 2300 Stratford Ave Willow Grove PA 19090
| | - David M. Martin
- Drug Enforcement Administration Educational Foundation 2020 Pennsylvania Ave Washington DC 20006
| | - Thom Browne
- The Colombo Plan 31 Wijerama Mawatha Colombo 7 Sri Lanka
| | - Jeremy Triplett
- Kentucky State Police Central Forensic Laboratory 100 Sower Blv Frankfurt KY 40601
| | - Trisha Conti
- Vermont Forensic Laboratory 45 State Drive Waterbury VT 05671
| | - Barry K. Logan
- The Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation 2300 Stratford Ave Willow Grove PA 19090
- NMS Labs 3701 Welsh Road Willow Grove PA 19090
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Schieppati F, Gregorini G, Hummel AM, D'Adda M, Borlenghi E, Lamorgese C, Specks U, Rossi G. Acquired cyclic neutropenia associated with cocaine-induced anti-neutrophil cytoplasmic antibodies binding to human neutrophil elastase. Am J Hematol 2018; 93:E227-E229. [PMID: 29999538 DOI: 10.1002/ajh.25197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 06/09/2018] [Accepted: 06/11/2018] [Indexed: 11/10/2022]
Affiliation(s)
| | - Gina Gregorini
- Department of Nephrology; ASST Spedali Civili di Brescia; Brescia Italy
| | - Amber M. Hummel
- Division of Pulmonary and Critical Care Medicine; Mayo Clinic; Rochester Minnesota
| | - Mariella D'Adda
- Department of Hematology; ASST Spedali Civili di Brescia; Brescia Italy
| | - Erika Borlenghi
- Department of Hematology; ASST Spedali Civili di Brescia; Brescia Italy
| | - Cinzia Lamorgese
- Department of Hematology; ASST Spedali Civili di Brescia; Brescia Italy
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine; Mayo Clinic; Rochester Minnesota
| | - Giuseppe Rossi
- Department of Hematology; ASST Spedali Civili di Brescia; Brescia Italy
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Dartevel A, Chaigne B, Moachon L, Grenier F, Dupin N, Guillevin L, Bouillet L, Mouthon L. Levamisole-induced vasculopathy: A systematic review. Semin Arthritis Rheum 2018; 48:921-926. [PMID: 30166200 DOI: 10.1016/j.semarthrit.2018.07.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 06/27/2018] [Accepted: 07/23/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To characterize levamisole-induced vasculopathy. METHODS We performed a systematic review searching MEDLINE for articles published from 1972 to 2016. RESULTS We retrieved 357 references and abstracts and selected 111 articles. Levamisole-induced vasculopathy was reported in 192 patients, with a female predominance (n = 122, 63.5%). Median [interquartile range] age was 44 [38-50]. Skin was the most frequently involved organ (n = 182, 94.8%). Cutaneous lesions were mostly on the face (n = 136, 70.8%), especially the ears. Purpura (n = 131, 68.2%) was the most reported cutaneous lesion. Organ involvement included acute renal failure (n = 24, 12.5%), and pulmonary involvement (n = 20, 10.4%). Anti-neutrophil cytoplasmic antibodies (ANCAs) were found in 167/178 patients (93.8%), with both anti-myeloperoxydase and anti-proteinase 3 specificity reported in 51/118 patients (43.2%). Anti-phospholipid (APL) antibodies were found in 93/137 patients (67.9%). Leukopenia was detected in 69/138 patients (50%). Skin biopsies identified vasculitis and thrombotic vasculopathy in 73/148 (49.3%) and 62/148 (41.9%) patients, respectively. The outcome was favourable in 116/134 patients (86.6%), but relapses were reported in 33 (28.4%), mainly on levamisole re-exposure. CONCLUSION Levamisole-induced vasculopathy is characterized by a female predominance, skin involvement, ANCA and/or APL antibody positivity, leukopenia, vasculitis or vascular thrombotic histological lesions, and despite possible systemic involvement, a favourable outcome with levamisole interruption.
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Affiliation(s)
- Anaïs Dartevel
- Service de Médecine Interne, hôpital Cochin, Centre de Référence pour les maladies systémiques autoimmunes rares d'Ile de France, DHU Authors (Autoimmune and Hormonal Diseases), Université Paris Descartes, Sorbonne Paris Cité, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; Service de Médecine Interne, Centre national de référence des angiœdème (CREAK), Universités des Alpes-Grenoble 1, 38041 Grenoble, France
| | - Benjamin Chaigne
- Service de Médecine Interne, hôpital Cochin, Centre de Référence pour les maladies systémiques autoimmunes rares d'Ile de France, DHU Authors (Autoimmune and Hormonal Diseases), Université Paris Descartes, Sorbonne Paris Cité, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Laurence Moachon
- Service de Pharmacologie, Hôpital Cochin, AP-HP, and Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Florian Grenier
- Service de médecine légale, Universités des Alpes-Grenoble 1, 38041 Grenoble, France
| | - Nicolas Dupin
- Service de Dermatologie, Hôpital Cochin, AP-HP, and Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Loïc Guillevin
- Service de Médecine Interne, hôpital Cochin, Centre de Référence pour les maladies systémiques autoimmunes rares d'Ile de France, DHU Authors (Autoimmune and Hormonal Diseases), Université Paris Descartes, Sorbonne Paris Cité, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Laurence Bouillet
- Service de Médecine Interne, Centre national de référence des angiœdème (CREAK), Universités des Alpes-Grenoble 1, 38041 Grenoble, France
| | - Luc Mouthon
- Service de Médecine Interne, hôpital Cochin, Centre de Référence pour les maladies systémiques autoimmunes rares d'Ile de France, DHU Authors (Autoimmune and Hormonal Diseases), Université Paris Descartes, Sorbonne Paris Cité, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.
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13
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Cocaine/levamisole-associated autoimmune syndrome: a disease of neutrophil-mediated autoimmunity. Curr Opin Hematol 2018; 25:29-36. [PMID: 29211697 DOI: 10.1097/moh.0000000000000393] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Levamisole was previously used for its immunomodulatory properties to treat rheumatoid arthritis and some cancers. However, because of serious side-effects, it was taken off the market in the United States. Recently, levamisole has reemerged as a popular cocaine adulterant. Some individuals who consume levamisole-adulterated cocaine can develop a life-threatening autoimmune syndrome. In this review, the medical consequences of levamisole exposure and postulated mechanisms by which levamisole induces these adverse effects are discussed. RECENT FINDINGS Although agranulocytosis and cutaneous vasculitis are the major findings in patients who develop cocaine/levamisole-associated autoimmune syndrome (CLAAS), more recent experience indicates that other organ systems can be involved as well. Current studies point to neutrophil activation and neutrophil extracellular trap formation with subsequent antineutrophil cytoplasmic antibody-mediated tissue injury as a possible mechanism of CLAAS. SUMMARY In the past decade, the detrimental effects of levamisole have reemerged because of its popularity as a cocaine adulterant. Although infrequent, some individuals develop a systemic autoimmune syndrome characterized by immune-mediated agranulocytosis and antineutrophil cytoplasmic antibody-mediated vasculitis. Mechanistically, neutrophil antigens appear to be a major player in inducing CLAAS. Prompt cessation of levamisole exposure is key to treatment, although relapses are frequent because of the addictive effects of cocaine and the high prevalence of levamisole within the cocaine supply.
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Khan MS, Khan Z, Khateeb F, Moustafa A, Taleb M, Yoon Y. Recurrent Levamisole-Induced Agranulocytosis Complicated by Bowel Ischemia in a Cocaine User. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:630-633. [PMID: 29853712 PMCID: PMC6009213 DOI: 10.12659/ajcr.908898] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 03/05/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND 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.
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Affiliation(s)
- Mohammad Saud Khan
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, OH, U.S.A
| | - Zubair Khan
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, OH, U.S.A
| | - Faisal Khateeb
- Department of Pulmonary, Critical Care and Sleep Medicine, University of Toledo Medical Center, Toledo, OH, U.S.A
| | - Abdelmoniem Moustafa
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, OH, U.S.A
| | - Mohammad Taleb
- Department of Pulmonary, Critical Care and Sleep Medicine, University of Toledo Medical Center, Toledo, OH, U.S.A
| | - Youngsook Yoon
- Department of Pulmonary, Critical Care and Sleep Medicine, University of Toledo Medical Center, Toledo, OH, U.S.A
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A review of illicit psychoactive drug use in elective surgery patients: Detection, effects, and policy. Int J Surg 2017; 48:160-165. [PMID: 29104125 DOI: 10.1016/j.ijsu.2017.10.074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 10/30/2017] [Indexed: 12/30/2022]
Abstract
Limited information is present in literature regarding detection of illicit drug users visiting physicians when planning elective surgery; also, there is no update manuscript that is illustrating the effects of illicit drugs use that require reconstructive surgery interventions. Aims of this manuscript are: 1) to summarize existing knowledge, and give surgeons information how to detect patients who might possible use illicit drugs; 2) to review the effects of illicit drug use that specifically require reconstructive surgery interventions; 3) to assess on existing policies on asymptomatic illicit drug users when planning elective surgery. Studies were identified by searching systematically in the electronic databases PubMed, Medline, The Cochrane Library and SveMed+. Because of the nature of research questions to be investigated (drug policy and surgery), a "systematic review" was not possible. In spite of some existing policies to detect illicit drug use in specific situations such as workplaces or acute trauma patients, there is a lack of data and lack of information, and subsequently no policy has ever been made, for detection and management of illicit drug use asymptomatic patients requesting or referred for plastic surgery interventions. This manuscript poses questions for further ethical evaluations and future policy.
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Adverse effects of levamisole in cocaine users: a review and risk assessment. Arch Toxicol 2017; 91:2303-2313. [DOI: 10.1007/s00204-017-1947-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 02/23/2017] [Indexed: 10/19/2022]
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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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Jamey C, Kintz P, Raul JS. Lévamisole et cocaïne : une association à surveiller. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2016. [DOI: 10.1016/j.toxac.2015.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Roberts JA, Chévez-Barrios P. Levamisole-Induced Vasculitis: A Characteristic Cutaneous Vasculitis Associated With Levamisole-Adulterated Cocaine. Arch Pathol Lab Med 2015; 139:1058-61. [PMID: 26230600 DOI: 10.5858/arpa.2014-0107-rs] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Levamisole-induced vasculitis is a characteristic cutaneous vasculitis syndrome associated with the use of levamisole-adulterated cocaine. Patients will typically present with a painful, purpuric rash in a retiform or stellate pattern with or without central necrosis involving the extremities, trunk, nasal tip, digits, cheeks, and/or ears. A history of cocaine abuse can be elicited. Histologic features include microvascular thrombi and/or leukocytoclastic vasculitis involving small vessels of the superficial and deep dermis. Epidermal involvement is variably seen. Laboratory findings include leukopenia, neutropenia (including agranulocytosis), elevated erythrocyte sedimentation rate, normal coagulation studies, and positive autoantibodies including perinuclear and cytoplasmic antineutrophil cytoplasmic antibodies, antinuclear antibody, and lupus anticoagulant. Differential diagnosis includes other microscopic vasculitides, and clinical and laboratory correlation with histologic findings is essential. Lesions typically resolve with the cessation of cocaine use. Because of the treatment implications and rising incidence of this entity, rapid and accurate diagnosis is essential.
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Affiliation(s)
| | - Patricia Chévez-Barrios
- From the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas (Drs Roberts and Chévez-Barrios); and Weill Cornell Medical College of Cornell University, Houston, Texas (Dr Chévez-Barrios)
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Buxton JA, Omura J, Kuo M, Ross C, Tzemis D, Purssell R, Gardy J, Carleton B. Genetic determinants of cocaine-associated agranulocytosis. BMC Res Notes 2015; 8:240. [PMID: 26070312 PMCID: PMC4467676 DOI: 10.1186/s13104-015-1219-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 06/01/2015] [Indexed: 11/25/2022] Open
Abstract
Background Drug-induced agranulocytosis is a recognized adverse drug event associated with serious infectious complications. Levamisole is an antihelminthic and immunomodulator withdrawn from North American markets in 2005 after reports of agranulocytosis. Previous studies of levamisole, suggest that the human leukocyte antigen (HLA)-B27 confers a genetic predisposition to this adverse drug event. Since 2009, emergency room visits due to agranulocytosis in individuals consuming levamisole-adulterated crack-cocaine have increased. Methods We performed a case–control study using a genotyping assay and novel gene chip to test the association between cocaine-associated agranulocytosis (CAA) and HLA-B27 and to identify pharmacokinetic and pharmacodynamic gene variants associated with the phenotype. Results Fifty-one CAA cases were identified through a provincial physician reporting system between 2008 and 2011. We examined eight of these cases and 26 matched controls. Genotyping revealed a significant association between HLA-B27 and CAA (odds ratio [OR] 9.2, 95% confidence interval [CI], 1.54–54.6). We also observed a similar association with the HLA-B27 tag single nucleotide polymorphism rs4349859 (OR 9.2, 95% CI 1.5–54.6) and rs13202464 (OR 6.7, 95% CI 1.1–41). Further associations were identified with variants in the ARBCC12 (OR 10.0, 95% CI 2.7–36.8) and CYP11A1 (OR 7.4, 95% CI 2.1–26.6) genes, while a novel protective association was observed with variants in the ARDB1 gene (OR 0.06, 95% CI 0.007–0.46). Conclusions We confirmed the association of HLA-B27 with CAA and identified additional susceptibility variants. Health care providers should inform people who are identified as having CAA that it is genetically determined and can recur with continued cocaine use. The severity of infections and subsequent hospitalization, and the risk of recurrence may prompt health-promoting behaviour changes of the affected individuals. These genetic associations warrant the attention of public health and knowledge translation efforts to highlight the implications for susceptibility to this severe adverse drug event.
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Affiliation(s)
- Jane A Buxton
- BC Center for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada. .,School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada.
| | - John Omura
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada.
| | - Margot Kuo
- BC Center for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada.
| | - Colin Ross
- Child and Family Research Institute, 950 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada.
| | - Despina Tzemis
- BC Center for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada.
| | - Roy Purssell
- Drug and Poison Information Centre, BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada.
| | - Jennifer Gardy
- BC Center for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada. .,School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada.
| | - Bruce Carleton
- Child and Family Research Institute, 950 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada.
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Schillberg E, Isaac M, Deng X, Peirano G, Wylie JL, Van Caeseele P, Pillai DR, Sinnock H, Mahmud SM. Outbreak of invasive Streptococcus pneumoniae serotype 12F among a marginalized inner-city population in Winnipeg, Canada, 2009-2011. Clin Infect Dis 2014; 59:651-7. [PMID: 24842908 DOI: 10.1093/cid/ciu366] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND In 2010, Winnipeg, Canada, experienced a doubling of invasive pneumococcal disease (IPD) rates, with a significant increase in the number of cases due to Streptococcus pneumoniae serotype 12F, which previously had accounted for very few cases each year. METHODS All serotype 12F IPD cases reported between September 2009 and January 2011 were reviewed. Pulsed-field gel electrophoresis (PFGE) and multilocus variable number tandem repeat analysis (MLVA) were conducted on all isolates. PFGE and MLVA patterns identified several possible clusters. Additional interviews were conducted to obtain information on risk factors and outcomes. RESULTS Between September 2009 and January 2011, 169 cases of IPD were identified. The number of IPD cases due to 12F serotype increased sharply from about 3-4 cases per year (6% of IPD cases) in 2007-2009 to 28 (29%) in 2010. All 12F isolates belonged to a single sequence type (ST218), and they were generally susceptible to penicillin and fluoroquinolones but not to erythromycin. Compared with cases caused by other serotypes, patients with serotype 12F were more likely to be homeless, reside in low-income inner-city communities, and engage in substance abuse, including intravenous and crack cocaine use. Subclusters identified using MLVA had even higher rates of homelessness and substance use. CONCLUSIONS An immunization campaign targeting high-risk groups was undertaken with pneumococcal polysaccharide vaccine, and subsequently rates of serotype 12F decreased. To our knowledge, this is the largest documented community outbreak of serotype 12F IPD and the first report of an outbreak of IPD serotype 12F in a marginalized urban population in Canada.
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Affiliation(s)
| | - Michael Isaac
- Vaccine and Drug Evaluation Centre, Department of Community Health Sciences, University of Manitoba, Winnipeg
| | - Xianding Deng
- Department of Laboratory Medicine and Pathobiology, University of Toronto
| | - Gisele Peirano
- Department of Pathology and Laboratory Medicine, University of Calgary Calgary Laboratory Services
| | - John L Wylie
- Cadham Provincial Laboratory Department of Medical Microbiology
| | | | - Dylan R Pillai
- Department of Pathology and Laboratory Medicine, University of Calgary Calgary Laboratory Services
| | - Hasantha Sinnock
- Vaccine and Drug Evaluation Centre, Department of Community Health Sciences, University of Manitoba, Winnipeg
| | - Salaheddin M Mahmud
- Winnipeg Regional Health Authority Vaccine and Drug Evaluation Centre, Department of Community Health Sciences, University of Manitoba, Winnipeg Faculty of Pharmacy, University of Manitoba, Winnipeg, Canada
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Giné CV, Espinosa IF, Vilamala MV. New psychoactive substances as adulterants of controlled drugs. A worrying phenomenon? Drug Test Anal 2014; 6:819-24. [DOI: 10.1002/dta.1610] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 12/23/2013] [Accepted: 12/23/2013] [Indexed: 11/10/2022]
Affiliation(s)
- Claudio Vidal Giné
- Energy Control - Asociación Bienestar y Desarrollo; Quevedo 2 bajos 08012 Barcelona Spain
| | - Iván Fornís Espinosa
- Energy Control - Asociación Bienestar y Desarrollo; Quevedo 2 bajos 08012 Barcelona Spain
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García Pérez MR, Ortiz-González VL, Betancourt M, Mercado R. Cocaine-induced vasculitis: is this a new trend? Open Access Rheumatol 2013; 5:77-80. [PMID: 27790026 PMCID: PMC5074789 DOI: 10.2147/oarrr.s51524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Cocaine-induced vasculitis is a rare complication found in drug abusers. It occurs due to cocaine adulterated with levamisole. Levamisole was once used as a chemotherapy and immunomodulator for different conditions. One of the side effects of this medication is necrotizing vasculitis which has been reported in the US and Puerto Rico. Here we present another case of cocaine induced vasculitis in Puerto Rico. We describe a 43-year-old female with past medical history of bronchial asthma, migraine, and crack smoking who presented to the emergency room due to blood in her urine for 5 days. She also reported fever, chills, and fatigue. At the physical exam she had a right knee ulcer with swelling erythema, warmth, and pain. Also, she had retiform purpuric plaque lesions in her ears, bilaterally. Eroded plaques with elevated borders at left foot and finger dorsum were also present. Laboratory workup was positive for cocaine. The patient showed leucopenia and microcytic anemia with a normal absolute neutrophil count in her cell blood count. Blood cultures, urine cultures, and ulcer cultures were negative. Urinalysis was positive for proteinuria and hematuria. Also, the patient had positive perinuclear anti-neutrophil cytoplasmic antibody, cytoplasmic anti-neutrophil cytoplasmic antibody, and antinuclear antibody tests and elastase specificity. She showed negative anticardiolipin and lupus anticoagulant antibodies. Her complement levels were decreased. The punch biopsy of her ear showed superficial thrombosis of superficial vascular plexus with perivascular lymphocytic infiltrates and deeper sections showed epidermal necrosis and necrotizing vasculitis. She was started on a high dose of steroids, but could not complete the treatment because she escaped from the hospital before finishing her treatment.
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Affiliation(s)
| | | | | | - Rogelio Mercado
- Department of Dermatology, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
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Crowe DR, Kim PS, Mutasim DF. Clinical, histopathologic, and immunofluorescence findings in levamisole/cocaine-induced thrombotic vasculitis. Int J Dermatol 2013; 53:635-7. [DOI: 10.1111/j.1365-4632.2012.05667.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Controlling chaos: the perceptions of long-term crack cocaine users in vancouver, british columbia, Canada. JOURNAL OF ADDICTION 2013; 2013:851840. [PMID: 24826370 PMCID: PMC4008449 DOI: 10.1155/2013/851840] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 06/17/2013] [Accepted: 06/26/2013] [Indexed: 11/30/2022]
Abstract
People who smoke crack cocaine are described as chaotic and more likely to engage in risky sex, polysubstance use and contract infectious diseases. However, little is known about how individuals perceive smoking crack as compared to other forms of cocaine use, especially injection. We explored the lived experience of people who smoke crack cocaine. Six gender-specific focus groups (n = 31) of individuals who currently smoke crack in Vancouver, Canada, were conducted using a semi-structured interview guide. Focus groups were transcribed and analyzed by constant comparative methodology. We applied Rhodes' risk environment to the phenomenological understanding that individuals have regarding how crack has affected their lives. Subjects reported that smoking rather than injecting cocaine allows them to begin “controlling chaos” in their lives. Controlling chaos was self-defined using nontraditional measures such as the ability to maintain day-to-day commitments and housing stability. The phenomenological lens of smoking crack instead of injecting cocaine “to control chaos” contributes a novel perspective to our understanding of the crack-smoking population. This study examines narratives which add to prior reports of the association of crack smoking and increased chaos and suggests that, for some, inhaled crack may represent efforts towards self-directed harm reduction.
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Hennings C, Miller J. Illicit drugs: What dermatologists need to know. J Am Acad Dermatol 2013; 69:135-42. [DOI: 10.1016/j.jaad.2012.12.968] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Revised: 12/11/2012] [Accepted: 12/16/2012] [Indexed: 10/27/2022]
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Vagi SJ, Sheikh S, Brackney M, Smolinske S, Warrick B, Reuter N, Schier JG. Passive multistate surveillance for neutropenia after use of cocaine or heroin possibly contaminated with levamisole. Ann Emerg Med 2013; 61:468-74. [PMID: 23374417 PMCID: PMC11152142 DOI: 10.1016/j.annemergmed.2012.10.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Revised: 09/23/2012] [Accepted: 10/22/2012] [Indexed: 10/27/2022]
Abstract
STUDY OBJECTIVE To characterize the demographic, clinical, and epidemiologic features of levamisole-associated neutropenia in cocaine or heroin users. METHODS State health departments were recruited for participation when the Centers for Disease Control and Prevention (CDC) was notified of potential cases by a clinician, a health department official, or a poison center between October 15, 2009, and May 31, 2010. A case was defined as a person with an absolute neutrophil count less than 1,000 cells/μL (or a WBC count <2,000 cells/μL) and a self-reported history or laboratory confirmation of cocaine or heroin use. Health department officials abstracted data from medical charts, attempted a patient interview, and submitted data to CDC for descriptive analysis. RESULTS Of the 46 potential cases reported from 6 states, half met eligibility criteria and had medical chart abstractions completed (n=23; 50%). Of these, close to half of the patients were interviewed (n=10; 43%). The average age was 44.4 years; just over half were men (n=12; 52%). The majority of patients presented to emergency departments (n=19; 83%). More than half presented with infectious illnesses (n=12; 52%), and nearly half reported active skin lesions (n=10; 44%). The majority of interview respondents used cocaine greater than 2 to 3 times a week (n=9; 90%), used cocaine more than 2 years (n=6; 60%), and preferred crack cocaine (n=6; 60%). All were unaware of exposure to levamisole through cocaine and of levamisole's inherent toxicity (n=10; 100%). CONCLUSION Physicians should suspect levamisole exposure in patients using illicit drugs, cocaine in particular, who present with unexplained neutropenia. Most patients reported chronic cocaine use and were unaware of levamisole exposure. Cocaine use is more prevalent among men; however, our results identified a higher-than-expected proportion of female users with neutropenia, suggesting women may be at higher risk. Emergency physicians and practitioners are uniquely positioned to recognize these patients early during their hospital course, elucidate a history of cocaine or other drug exposure, and optimize the likelihood of confirming exposure by arranging for appropriate drug testing.
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Abstract
The prevalence of cocaine-induced pseudovasculitis (CIP) causing cutaneous destruction is increasing, and plastic surgeons need to be aware of this condition because they are a part of the multidisciplinary treatment team. Differentiation of CIP from a true autoimmune vasculitis can be exceedingly challenging, and misdiagnosis with ensuing treatment may be fatal. This article is a succinct review of CIP, guided by a clinical case of 30% total body surface area skin necrosis, to familiarize the reader with this syndrome. Diagnostic aids include history of cocaine use, localized disease manifestation to skin or mucosa, discordance of antineutrophil cytoplasmic antibody and target antibody patterns typical for true vasculitis, and testing for antihuman neutrophil elastase and levamisole. Treatment is primarily supportive, and wound care, with regard to dressings and surgery, is a cross between to that of burns and meningococcemia patients.
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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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Metwally O, Hamidi M, Townsend L, Abualula H, Zaitoun A, Lall T. The Cocaine Trail: Levamisole-Induced Leukocytoclastic Vasculitis in a Cocaine User. Subst Abus 2013; 34:75-7. [DOI: 10.1080/08897077.2012.718318] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Freyer CW, Peters M. Palpable purpura complicated by streptococcal toxic shock syndrome resulting in limb necrosis and amputation: a case of levamisole and cocaine coingestion. Pharmacotherapy 2012; 32:e17-23. [PMID: 22392427 DOI: 10.1002/phar.1012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Palpable purpura resulting from cocaine and levamisole coingestion has been reported with increasing frequency over the last several years as distribution of this drug combination becomes more universal. Toxicity from ingestion of this dangerous combination is difficult to diagnose due to the multitude of possible clinical presentations, variety of possible adulterants, and elusive nature of levamisole given its short half-life and limited availability of detection methods. Levamisole is a chemotherapeutic and immunomodulatory agent currently marketed as a veterinary anthelmintic. We describe the case of a 48-year-old woman admitted to our intensive care unit with a diagnosis of streptococcal toxic shock syndrome (STSS), confirmed from fluid taken from an elbow lesion that grew Streptococcus pyogenes. She was noted to have bullae of the elbow and diffuse purpura with necrotic centers covering a large portion of her body (trunk, legs, arms, back, toes, fingers, and tip of nose). On further evaluation, she was found to have ingested levamisole-tainted cocaine. The patient's complications related to either cocaine and levamisole coingestion or STSS included thrombocytopenia, acute renal failure, and limb necrosis. Thrombocytopenia gradually improved upon treatment with prednisone, and acute renal failure improved with intravenous fluid resuscitation; however, she subsequently required several appendage amputations due to severe gangrene. Clinicians must have high suspicion for ingestion of this drug combination and request prompt testing of urine samples for levamisole if a patient who admits to illicit drug use presents with purpuric or necrotic skin lesions.
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Affiliation(s)
- Craig W Freyer
- Department of Pharmacy, Henry Ford Hospital, Detroit, Michigan, USA.
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Wu AH, Gerona R, Armenian P, French D, Petrie M, Lynch KL. Role of liquid chromatography–high-resolution mass spectrometry (LC-HR/MS) in clinical toxicology. Clin Toxicol (Phila) 2012; 50:733-42. [DOI: 10.3109/15563650.2012.713108] [Citation(s) in RCA: 123] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Levamisole-induced vasculopathy: a report of 2 cases and a novel histopathologic finding. Am J Dermatopathol 2012; 34:208-13. [PMID: 22094232 DOI: 10.1097/dad.0b013e31821cc0bf] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although cocaine-induced pseudovasculitis and urticarial vasculitis have been reported in the past, levamisole-induced vasculopathy with ecchymosis and necrosis, termed here LIVEN, has only recently been described in association with cocaine use. Levamisole, a veterinary antihelminthic agent used previously as an immunomodulating agent, is present as a "cutting agent" in approximately two-thirds of the cocaine currently entering the United States. Levamisole is believed to potentiate the effects of cocaine and may also be used as a "signature" for tracing its market distribution. Herein, we report 2 cases of LIVEN in patients with histories of chronic cocaine use. In both the cases, a temporal association with neutropenia preceding the eruption was noted. A novel histopathologic finding present only in the second case was the presence of extensive interstitial and perivascular neovascularization. Our 2 cases reaffirm that neutropenia may precede the cutaneous eruption of LIVEN. Case 2 extends the spectrum of histopathologic findings to include the novel phenomenon of neovascularization-hitherto unreported in this entity.
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Khan TA, Cuchacovich R, Espinoza LR, Lata S, Patel NJ, Garcia-Valladares I, Salassi MM, Sanders CV. Vasculopathy, hematological, and immune abnormalities associated with levamisole-contaminated cocaine use. Semin Arthritis Rheum 2012; 41:445-54. [PMID: 22152487 DOI: 10.1016/j.semarthrit.2011.04.010] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 04/27/2011] [Accepted: 04/29/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To report 4 cases of cocaine-related purpura and to review previously reported cases of levamisole, levamisole-contaminated cocaine, and cocaine-induced vasculopathy. METHODS We describe 4 patients suspected of vasculopathy associated with levamisole-tainted cocaine use. A retrospective review of the literature was performed using the PubMed, PubJet, MD consult, and Cochrane review databases. RESULTS Four cases (2 females and 2 males), 46 to 55 years of age, presented with cocaine-related purpura, mainly affecting the ears, neutropenia, and autoantibodies. Skin biopsies revealed a mixed pattern of leukocytoclastic vasculitis and microvascular thrombosis in 2 cases, and pure thrombosis in the third case. The mixed vasculopathic pattern in association with neutropenia, both known adverse effects of levamisole, and levamisole positivity in 2 cases point to this compound as the true etiologic agent in our patients. Eleven cases of levamisole-contaminated cocaine-induced vasculopathy have been described in the English literature. Among these, 10 were females. Age range was 22 to 57 years. Urine levamisole positivity was tested and confirmed in 3 of the 11 cases. The clinical characteristics, laboratory features, histology, treatment, and recovery rates were compared for the published cases of levamisole, levamisole-contaminated cocaine, and cocaine-induced vasculopathy. CONCLUSIONS Adulterated cocaine abuse is an increasingly recognized phenomenon in North America. Levamisole is among the many contaminants that have been detected in seized cocaine throughout North America and Europe. Recent reports described an association between levamisole-tainted cocaine and purpuric skin rash, neutropenia, and the presence of autoantibodies.
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Affiliation(s)
- Tahir A Khan
- Section of Rheumatology, LSU Health Sciences Center, New Orleans, LA, USA
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Belfonte CD, Shanmugam VK, Kieffer N, Coker S, Boucree S, Kerr G. Levamisole-induced occlusive necrotising vasculitis in cocaine abusers: an unusual cause of skin necrosis and neutropenia. Int Wound J 2012; 10:590-6. [PMID: 22716045 DOI: 10.1111/j.1742-481x.2012.01027.x] [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] [Indexed: 10/28/2022] Open
Abstract
We present three cases describing the various skin manifestations of presumed levamisole-contaminated cocaine use. Antibody-mediated vasculitis and neutropenia were consistent findings in these cases and repeat exposure resulted in distinct dermatologic complications. This phenomenon of levamisole-induced vasculitis and neutropenia is being increasingly described and has characteristic wound manifestations that must be recognised and treated early.
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Affiliation(s)
- Cassius D Belfonte
- Division of Cardiology, Howard University Hospital, Washington, DC, USA Division of Rheumatology, Immunology and Allergy, Georgetown University Hospital, Washington, DC, USA Division of Rheumatology, Veterans Affairs Hospital, Washington, DC, USA Department of Internal Medicine, Howard University Hospital, Washington, DC, USA
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Winistoerfer NM. Clinical Pearl: Levamisole-induced vasculitis with necrosis in chronic cocaine users. Ment Health Clin 2012. [DOI: 10.9740/mhc.n109214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This case reveals an additional risk faced by persons who abuse substances, specifically when such substances are adulterated. Levamisole, often used to falsely extend the quantity of cocaine a person believes he is purchasing, is known to have life-threatening adverse events. In this case, a chronic cocaine user developed vasculitis from impure cocaine.
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Lee KC, Ladizinski B, Federman DG. Complications associated with use of levamisole-contaminated cocaine: an emerging public health challenge. Mayo Clin Proc 2012; 87:581-6. [PMID: 22677078 PMCID: PMC3498128 DOI: 10.1016/j.mayocp.2012.03.010] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 03/21/2012] [Accepted: 03/27/2012] [Indexed: 10/28/2022]
Abstract
Levamisole is an immunomodulatory agent that was used to treat various cancers before being withdrawn from the United States market in 2000 because of adverse effects. Levamisole is currently approved as an antihelminthic agent in veterinary medicine, but is also being used illicitly as a cocaine adulterant. Potential complications associated with use of levamisole-laced cocaine include neutropenia, agranulocytosis, arthralgias, retiform purpura, and skin necrosis. Treatment is primarily supportive, and skin lesions typically resolve with cessation of cocaine use. The incidence of hospitalizations related to use of levamisole-contaminated cocaine continues to increase and clinicians should be aware of the more common clinical manifestations.
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Affiliation(s)
- Kachiu C. Lee
- Department of Dermatology, Brown University, Providence, RI
| | - Barry Ladizinski
- Department of Dermatology, Duke University Medical Center, Durham, NC
| | - Daniel G. Federman
- Department of Internal Medicine, VA Connecticut Healthcare System, West Haven
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Necrotizing peripheral vasculitis/vasculopathy following the use of cocaine laced with levamisole. J Burn Care Res 2012; 33:e6-e11. [PMID: 22138808 DOI: 10.1097/bcr.0b013e318235615a] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The objective of this study was to describe a novel presentation of peripheral vasculitis associated with levamisole-adulterated cocaine. Cocaine abuse is widespread in the United States with 5.3 million people using cocaine in 2008. Over the past decade, drug enforcement officials have noticed the presence of levamisole in confiscated cocaine samples as an adulterant. Known side effects of cocaine-related levamisole ingestion have included agranulocytosis and a cutaneous acral purpura that is histopathologically characterized by a mixture of inflammation (vasculitis) and occlusion (vasculopathy). A 54-year-old man who nasally ingested cocaine laced with levamisole developed widespread necrotic/purpuric skin lesions on approximately 20% of his body with an acral accentuation. These lesions were complicated by multiple areas of sloughing and necrosis. He was initially treated with topical silver sulfadiazine dressing changes but progressed to require debridement and split-thickness skin grafting. Peripheral vasculitis/vasculopathy with severe necrosis resembling Coumadin necrosis is a relatively recently recognized sequelae from levamisole-adulterated cocaine use.
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Larocque A, Hoffman RS. Levamisole in cocaine: unexpected news from an old acquaintance. Clin Toxicol (Phila) 2012; 50:231-41. [PMID: 22455354 DOI: 10.3109/15563650.2012.665455] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Levamisole is a pharmaceutical with anthelminthic and immunomodulatory properties that was previously used in both animals and humans to treat inflammatory conditions and cancer. Levamisole has been identified as a cocaine adulterant in the United States since 2003. By 2009, the United States Drug Enforcement Administration (DEA) estimated that 69% of the cocaine seized contained levamisole. The first case reports of complications related to levamisole in cocaine users were published in 2009. The objectives of this article are to review the literature regarding the full spectrum of possible complications related to levamisole use for medical purposes, to review the current scope of levamisole-induced complications in cocaine users and to discuss the pharmacological properties that might explain the motivation behind the large-scale adulteration of cocaine with levamisole. Literature review revealed that significant complications were quickly reported when levamisole was used in inflammatory conditions. By 1976, several cases of leukopenia and agranulocytosis were reported. Recurrence with re-exposure was well described and agranulocytosis spontaneously reversed upon discontinuation of therapy. Vasculitis secondary to levamisole treatment was first reported in 1978 and mostly manifests as leukocytoclastic vasculitis, cutaneous necrotising vasculitis and thrombotic vasculopathy without vasculitis. These findings typically, but not invariably, involve the ear lobes. Discontinuation of levamisole therapy was again a critical part of the treatment. Various neurological side effects were described with levamisole therapy, the most concerning complication being multifocal inflammatory leukoencephalopathy (MIL). Literature review identified 203 unique cases of complications in cocaine users that can be attributed to levamisole adulteration. The two principal complications reported are haematological (140 cases of neutropenia) and dermatological (84 cases). Even though these complications can occur in isolation, many cases displayed both simultaneously. No formal case of leukoencephalopathy in the setting of cocaine use has been reported so far. A striking phenomenon is the apparent high level of recurrence (27.1%) of symptoms in cocaine users after re-exposure to cocaine that is presumably adulterated. The importance of accurately identifying levamisole-induced complications is therefore critical for symptomatic patients as discontinuation of exposure is fundamental and as a correct diagnosis prevents unnecessary and potentially dangerous use of other treatment modalities like powerful immunosuppressive therapy. Literature review suggests that levamisole might have the advantages of enhancing noradrenergic neurotransmission by inhibiting reuptake, by inhibiting MAO and/or COMT, by acting on ganglionic nicotinic receptors and by being partially metabolized into an amphetamine-like compound. It could also increase endogenous opioids and increase dopamine concentration in the cerebral reward pathway. These potential effects make levamisole an interesting choice as a cocaine adulterant. It seems unlikely that levamisole use as a cocaine adulterant will soon reach an end. More information is needed about the diagnosis and treatment of levamisole-induced complications, and the efforts of the medical and public health community is needed to face this challenging problem.
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Affiliation(s)
- Alexandre Larocque
- Emergency Medicine Department, Centre Hospitalier de l'Université de Montréal, Clinical Toxicology Service, McGill University Health Center, Centre Antipoison du Québec, Montreal, Quebec, Canada.
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Casale JF, Colley VL, LeGatt DF. Determination of Phenyltetrahydroimidazothiazole Enantiomers (Levamisole/Dexamisole) in Illicit Cocaine Seizures and in the Urine of Cocaine Abusers via Chiral Capillary Gas Chromatography-Flame-Ionization Detection: Clinical and Forensic Perspectives. J Anal Toxicol 2012; 36:130-5. [DOI: 10.1093/jat/bkr025] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Cocaine Induced Vasculitis: Have We Found a Culprit? Case Rep Rheumatol 2012; 2012:982361. [PMID: 23346447 PMCID: PMC3546447 DOI: 10.1155/2012/982361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 12/05/2012] [Indexed: 11/18/2022] Open
Abstract
Cocaine abuse is relatively common in our society. To enhance profitability and acceptability of the product, it is not uncommon for illicit drugs to undergo several processes. The Drug Enforcement Agency (DEA) has reported that seventy percent (70%) of cocaine seized at USA borders has been adulterated with levamisole, previously used as chemotherapeutic and immunomodulator for several conditions. Among the side effects of levamisole-adulterated cocaine, necrotizing vasculitis is the more dramatic. We report three cases of necrotizing vasculitis associated with antineutrophils cytoplasmic antibodies (ANCAs) positivity, linked to the use of cocaine. To our knowledge, these are the first cases of cocaine induced vasculitis reported in the Caribbean.
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A case of levamisole-induced systemic vasculitis and cocaine-induced midline destructive lesion: a case report. J Clin Rheumatol 2011; 17:197-200. [PMID: 21617545 DOI: 10.1097/rhu.0b013e31821cb9d5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We describe a case of antineutrophil cytoplasmic antibody-positive vasculitis from levamisole-tainted cocaine with concomitant cocaine-induced midline destructive lesions of the palate and nasal septum. The diagnosis was confirmed after extensive clinical, laboratory, pathologic, and radiographic testing. Timely recognition of this clinical entity is critical to avoid misdiagnosis and unnecessary treatment with potentially harmful cytotoxic agents. Given the high rate of levamisole contamination within the nation's cocaine supply, clinicians should be alerted to this emerging health threat.
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Poon SH, Baliog CR, Sams RN, Robinson-Bostom L, Telang GH, Reginato AM. Syndrome of Cocaine-Levamisole-Induced Cutaneous Vasculitis and Immune-Mediated Leukopenia. Semin Arthritis Rheum 2011; 41:434-44. [DOI: 10.1016/j.semarthrit.2011.05.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2010] [Revised: 05/24/2011] [Accepted: 05/25/2011] [Indexed: 11/13/2022]
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McGrath MM, Isakova T, Rennke HG, Mottola AM, Laliberte KA, Niles JL. Contaminated cocaine and antineutrophil cytoplasmic antibody-associated disease. Clin J Am Soc Nephrol 2011; 6:2799-805. [PMID: 21980179 DOI: 10.2215/cjn.03440411] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Approximately 70% of illicit cocaine consumed in the United States is contaminated with levamisole. Most commonly used as a veterinary antihelminthic agent, levamisole is a known immunomodulating agent. Prolonged use in humans has been associated with cutaneous vasculitis and agranulocytosis. We describe the development of a systemic autoimmune disease associated with antineutrophil cytoplasmic antibodies (ANCA) in cocaine users. This complication appears to be linked to combined cocaine and levamisole exposure. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Cases were identified between March 2009 and November 2010 at Massachusetts General Hospital's ANCA laboratory. Cocaine exposure was identified from patient history in all cases. Medical records were reviewed for clinical presentation and for laboratory and diagnostic evaluation. RESULTS Thirty cases of ANCA positivity associated with cocaine ingestion were identified. All had antimyeloperoxidase antibodies and 50% also had antiproteinase 3 antibodies. Complete clinical and laboratory data were available for 18 patients. Arthralgia (83%) and skin lesions (61%) were the most frequent complaints at presentation. Seventy-two percent of patients reported constitutional symptoms, including fever, night sweats, weight loss, or malaise. Four patients had biopsy-proven vasculitis. Two cases of acute kidney injury and three cases of pulmonary hemorrhage occurred. From the entire cohort of 30, two cases were identified during the first 3 months of our study period and nine cases presented during the last 3 months. CONCLUSIONS We describe an association between the ingestion of levamisole-contaminated cocaine and ANCA-associated systemic autoimmune disease. Our data suggest that this is a potentially life-threatening complication of cocaine use.
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Affiliation(s)
- Martina M McGrath
- Renal Division, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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Lee KC, Culpepper K, Kessler M. Levamisole-induced thrombosis: Literature review and pertinent laboratory findings. J Am Acad Dermatol 2011; 65:e128-e129. [DOI: 10.1016/j.jaad.2011.05.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Revised: 05/14/2011] [Accepted: 05/22/2011] [Indexed: 10/17/2022]
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