Levamisole induced necrosis of the skin and neutropenia following intranasal cocaine use: a newly recognized syndrome

Levamisole is a veterinary anti-helminthic used to treat several autoimmune conditions but also commonly utilized as an additive in cocaine distribution. Toxicity resulting in agranulocytosis and cutaneous necrosis in association with cocaine use is an infrequently described phenomenon of an emerging problem. Although levamisole is found extensively in the cocaine supply of the United States, relatively few cases of necrotic skin lesions associated with intranasal use have been reported. The skin necrosis secondary to levamisole toxicity is characterized by variable findings on biopsy, ranging from leukocytoclastic vasculitis to occlusive vasculopathy. The following case describes a 54-year-old male who developed fever, agranulocytosis, p-ANCA autoantibodies and extensive skin necrosis following heavy intranasal cocaine use. Necrosis of greater than 50% of the patient's total body surface area resulted and was followed by thorough wound debridement.

An unusual cause of methaemoglobinaemia

Methaemoglobinaemia is a rare condition characterised by increased quantities of haemoglobin in which the iron of haem is oxidised to the ferric (Fe3+) form. Clinically the condition presents with cyanosis and low oxygen saturations on pulse oximetry but normal oxygen saturation on arterial blood gas analysis. Most cases are acquired and are frequently drug related. We present a case of methaemoglobinaemia which presented to our hospital.

Dose-Related Distribution of Codeine, Cocaine, and Metabolites into Human Hair following Controlled Oral Codeine and Subcutaneous Cocaine Administration

Hair testing for the determination of drug exposure has many useful applications. Drug incorporated into hair can be found for extended periods following drug exposure. There are few controlled drug administration studies investigating drug distribution into human hair. Ten volunteers participated in a 10-week controlled cocaine and codeine administration study while residing in the secure research ward. Weekly hair samples were collected by electric razor. During the low-dose week (week 4), volunteers received 75 mg/70 kg cocaine subcutaneously and 60 mg/70 kg codeine orally on alternating days, a total of three doses for each drug. Similarly, during week 7, volunteers received three doses 150 mg/70 kg cocaine and 120 mg/70 kg codeine. Maximum hair concentrations (C(max)) were found 1 to 3 weeks after low and high doses. Dose-related C(max) values of cocaine, benzoylecgonine, ecgonine methyl ester, norcocaine, cocaethylene, and codeine were found following low and high doses. Hair analysis was performed using liquid chromatography tandem mass spectrometry. A positive linear relationship was found between total melanin content of hair and C(max) of codeine, cocaine, and metabolites following high dosing. This study demonstrated dose-related concentrations of cocaine and metabolites in human hair following controlled cocaine administration. These data are the first demonstrating melanin-related incorporation of cocaine and metabolites into human hair following controlled cocaine administration.

Analysis of organic volatile impurities as a forensic tool for the examination of bulk pharmaceuticals

This discussion offers an overview of some formally accepted methodology in the USA for the determination of organic volatile impurities in pharmaceuticals. Particular advantages of equilibrium headspace sampling with capillary gas chromatography for this task are outlined and some important considerations are expressed. Specific adaptations which we have made for forensic applications are described along with mention of select applications within the context of the detection of the counterfeiting of bulk pharmaceuticals. Finally, a brief description is provided of statistical techniques which can be used to effectively manipulate multivariate data sets for purposes of distinguishing between the manufacturers of a product based upon impurity profiles.

Determination of cocaine concentrations in plasma by high-performance liquid chromatography

We describe a procedure for measuring concentrations of cocaine in plasma by reversed-phase high-performance liquid chromatography, with ion-pairing. The procedure involves solvent extraction followed by back-extraction with dilute acid. The n-propyl ester of benzoylecgonine is used as an internal standard. An evaporation step is not required, and concentrations as low as 5 micrograms/L can be quantified. Plasma concentrations of cocaine determined by high-performance liquid chromatography correlated well with those determined by a previously reported gas-chromatographic procedure with nitrogen detection.

A cluster of Mycobacterium gordonae isolates from bronchoscopy specimens

During a 2.5-year period, 52 patients at Yale-New Haven Hospital had Mycobacterium gordonae recovered from specimens obtained by suction at bronchoscopy; 2 of them also had smears positive for acid-fast bacilli. Almost all of the isolates came from patients bronchoscoped by the same physician, one of 4 who performed the procedure during that period. Only this physician added one drop of green dye, stored in a 100-ml bottle, to the cocaine used for topical anesthesia during the procedure; cultures of the dye yielded Mycobacterium gordonae. Contamination with this organism, a cause of positive acid-fast smears, may result in an initial inappropriate diagnosis of Mycobacterium tuberculosis.