Difference between revisions of "Levamisole toxicity"

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==Background==
 
==Background==
*an antihelminthic and immunomodulator that has been withdrawn from the U.S. and Canadian markets, due to the risk of serious side effects  
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*An antihelminthic and immunomodulator that has been withdrawn from the U.S. and Canadian markets, due to the risk of serious side effects  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
 
*Increasingly used as a cutting agent in cocaine sold around the globe
 +
**69% of DEA seized cocaine contained levamisole (2009)<ref> Larocque, L. Hoffman, R. Clinical Toxicology: Levamisole in cocaine: Unexpected news from an old acquaintance. (2012), 50, 231-234</ref>
 
*Results in Levamisole induced necrosis syndrome<ref>http://www.ncbi.nlm.nih.gov/pubmed/20668440</ref>
 
*Results in Levamisole induced necrosis syndrome<ref>http://www.ncbi.nlm.nih.gov/pubmed/20668440</ref>
  
 
==Clinical Features==
 
==Clinical Features==
*agranulocytosis
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[[File:PMC4456982 amjcaserep-16-310-g002.png|thumb|Leviamisole induced retiform purpura with hemorrhagic bullae in a patient with cocaine abuse<ref>Cocaine-induced delayed recurrent vasculitis: a 4-year follow-up.
**neutropenia
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Yogarajah M, Pervil-Ulysse M, Sivasambu B - Am J Case Rep (2015)</ref>]]
*levamisole induced necrosis syndrome
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*Agranulocytosis/Thrombocytopenia
 +
**Typically neutropenia
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**Tends to reverse spontaneously when discontinued
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*Levamisole induced necrosis syndrome
 
**Necrotic patches anywhere on skin (especially ears and legs)
 
**Necrotic patches anywhere on skin (especially ears and legs)
 +
*Leukoencephalopathy
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**Seen when used as a pharmaceutical in past
 +
**No cases described when associated with cocaine adulteration
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
 +
{{Necrotizing Rashes DDX}}
  
==Workup==
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==Evaluation==
 
*CBC
 
*CBC
  
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**Burn care if significant necrosis
 
**Burn care if significant necrosis
 
*Avoid cocaine re-exposure
 
*Avoid cocaine re-exposure
**27% of pts had symptom recurrence with cocaine re-exposure<ref>Larocque, L. Hoffman, R. Clinical Toxicology: Levamisole in cocaine: Unexpected news from an old acquaintance. (2012), 50, 231-234</ref>
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**27% of patients had symptom recurrence with cocaine re-exposure<ref>Larocque, L. Hoffman, R. Clinical Toxicology: Levamisole in cocaine: Unexpected news from an old acquaintance. (2012), 50, 231-234</ref>
  
 
==Disposition==
 
==Disposition==
Admission
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*Admission
  
 
==See Also==
 
==See Also==
 
*[[Cocaine]]
 
*[[Cocaine]]
 +
*[[Drug rash]]
  
 
==External Links==
 
==External Links==
  
==Sources==
+
==References==
 
<references/>
 
<references/>
  
[[Category:Tox]]
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[[Category:Toxicology]]

Latest revision as of 05:34, 1 February 2019

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)[1]
  • Results in Levamisole induced necrosis syndrome[2]

Clinical Features

Leviamisole induced retiform purpura with hemorrhagic bullae in a patient with cocaine abuse[3]
  • 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

Evaluation

  • CBC

Management

  • Neutropenia
  • Necrosis
    • Aggressive supportive care
    • Burn care if significant necrosis
  • Avoid cocaine re-exposure
    • 27% of patients had symptom recurrence with cocaine re-exposure[4]

Disposition

  • Admission

See Also

External Links

References

  1. Larocque, L. Hoffman, R. Clinical Toxicology: Levamisole in cocaine: Unexpected news from an old acquaintance. (2012), 50, 231-234
  2. http://www.ncbi.nlm.nih.gov/pubmed/20668440
  3. Cocaine-induced delayed recurrent vasculitis: a 4-year follow-up. Yogarajah M, Pervil-Ulysse M, Sivasambu B - Am J Case Rep (2015)
  4. Larocque, L. Hoffman, R. Clinical Toxicology: Levamisole in cocaine: Unexpected news from an old acquaintance. (2012), 50, 231-234