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• An antihelminthic and immunomodulator that has been withdrawn from the U.S. and Canadian markets, due to the risk of serious side effects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

Leviamisole induced retiform purpura with hemorrhagic bullae in a patient with cocaine abuse

• 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 when associated with cocaine adulteration

Differential Diagnosis

Necrotizing rashes

• Necrotizing soft tissue infections
  • Necrotizing fasciitis
  • Necrotizing myositis
  • Necrotizing cellulitis
• Purpura fulminans
• Drug rash
• Levamisole toxicity
• Heparin-induced skin necrosis
• Warfarin-induced skin necrosis

Evaluation

• CBC

Management

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

Disposition

Admission

See Also

• Cocaine
• Drug rash