Levamisole toxicity

Background

• an antihelminthic and immunomodulator that has been withdrawn from the U.S. and Canadian markets, due to the risk of serious side effects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

Clinical Features

• agranulocytosis/thrombocytopenia
  • typically neutropenia
  • tends to reverse spontaneously when discontinued
• levamisole induced necrosis syndrome
  • Necrotic patches anywhere on skin (especially ears and legs)
• leukoencephalopathy
  • seen when used as a pharmaceutical in past
  • no cases described associated with cocaine adulteration

Workup

• CBC

Management

• Neutropenia
  • Consider neupogen
  • Observation for neutropenic fever
• Necrosis
  • Aggressive supportive care
  • Burn care if significant necrosis
• Avoid cocaine re-exposure
  • 27% of pts had symptom recurrence with cocaine re-exposure

Disposition

Admission

See Also

• Cocaine