Internal Medicine · Vol. 2, No. 1 · 2018 · pp. e1–e3 · e-ISSN 2572-9233

Levamisole in Medicine

Fnu Nutan

Department of Internal Medicine, Division of Hospital Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA 23298, USAUnited States

DOI: https://doi.org/10.17140/imoj-2-e001 · Published 2018-02-28 · Licence: https://creativecommons.org/licenses/by/4.0 · © 2018 The Author(s)

Also available as PDF (figures and tables appear in the PDF).

Abstract

Levamisole is a common antihelminth used in veterinary medicine. It caught the attention of the medical community in 2008 when it was discovered to be the cause of agranulocytosis in people using illicit substances contaminated with levamisole. Subsequently multiple other deleterious effects have been recorded with the use of cocaine laced with this drug as discussed below.1 Prior to the widespread use of levamisole in cocaine, it was shown to cause the same deleterious effect in the pediatric population in whom it was used in chemotherapy regimen.

Conclusion

Given the widespread use of drugs of recreation, it is important for physicians to be aware of the various side effects caused by these drugs which may mimic known disease processes. Cocaine/ Levamisole adulterated autoimmune syndrome (CLAAS) is one such phenomenon which can be life-threatening in some patients with widespread organ damage. 13 Neutrophil activation is key to neutrophil extracellular trap formation resulting in ANCA positivity. In most patients, stopping the cocaine use usually helps with disease cessation but immunomodulators are sometimes required. There is always a danger of recurrence with repeated cocaine use. In this era, where opioid use epidemic is a national emergency, we have to educate the patients and the medical community about the ever increasing burden of consequences of drug abuse.

References

  1. Agranulocytosis associated with cocaine use-four States, March 2008-November 2009. MMWR Morb Mortal Wkly Rep. 2009; 58(49): 1381-1385. Web site. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5849a3.htm. Accessed February 21, 2018
  2. RongiolettiFGhioLGinevriF. Purpura of the ears: A distinctive vasculopathy with circulating autoantibodies complicating long-term treatment with levamisole in children. Br J Dermatol. 1999; 140(5): 948-951. doi: 10.1046/j.1365-2133.1999.02833.x10.1046/j.1365-2133.1999.02833.x https://doi.org/10.1046/j.1365-2133.1999.02833.x
  3. BuchananJALavonasEJ. Agranulocytosis and other consequences due to use of illicit cocaine contaminated with levamisole. Curr Opin Hematol. 2012; 19(1): 27-31. doi: 10.1097/ MOH.0b013e32834da9ef
  4. RaymonLPIsenschmidDS. Letter to the editor: The possible role of levamisole in illicit cocaine preparations. J Anal Toxicol. 2009. 33(9): 620-622. doi: 10.1093/jat/33.9.62010.1093/jat/33.9.620 https://doi.org/10.1093/jat/33.9.620
  5. McGrathMMIsakovaTRennkeHGMottolaAMLaliberteKANileJL. Contaminated cocaine and antineutrophil cytoplas mic antibody-associated disease. Clin J Am Soc Nephrol. 2011; 6(12): 2799-2805. doi: 10.2215/ CJN.03440411
  6. GaertnerEMSwitlykSA. Dermatologic complications from levamisole-contaminated cocaine: A case report and review of the literature. Cutis. 2014; 93(2): 102-106
  7. NutanFLadizinskiBLeeKC. Cutaneous manifestations of cocaine use. Cutis. 2014; 94(5): E6-E9
  8. JeongHSLayherHCaoLVandergriffTDominguezAR. Pyoderma gangrenosum (PG) associated with levamisole-adulter ated cocaine: Clinical, serologic, and histopathologic findings in a cohort of patients. J Am Acad Dermatol. 2016; 74(5): 892-898. doi: 10.1016/j.jaad.2015.11.04010.1016/j.jaad.2015.11.040 https://doi.org/10.1016/j.jaad.2015.11.040
  9. VittJRBrownEGChowDSJosephsonSA. Confirmed case of levamisole-associated multifocal inflammatory leukoencephalopathy in a cocaine user. J Neuroimmunol. 2017; 305: 128-130. doi: 10.1016/j.jneuroim.2017.01.01810.1016/j.jneuroim.2017.01.018 https://doi.org/10.1016/j.jneuroim.2017.01.018
  10. LiuYWMutnuriSSiddiquiSB. Levamisole-adulterated cocaine nephrotoxicity: Ultrastructural features. Am J Clin Pathol. 2016; 145(5): 720-726. doi: 10.1093/ajcp/aqw02910.1093/ajcp/aqw029 https://doi.org/10.1093/ajcp/aqw029
  11. Moinuddin I, Madhrira M, Bracamonte E, Thajudeen B, Suss man A. Membranous nephropathy with crescents associated with levamisole-induced MPO-ANCA vasculitis. Pathol Res Pract. 2016; 212(7): 650-653. doi: 10.1016/j.prp.2016.03.008 Intern Med Open J. 2018; 2(1): e1-e3. doi: 10.17140/IMOJ-2-e001 Nutan F Editorial | Volume 2 | Number 1| e3 https://doi.org/10.1016/j.prp.2016.03.008
  12. KarchSBBusardòFPVaianoFPortelliFZaamiSBertolE. Levamisole adulterated cocaine and pulmonary vasculitis: Presen tation of two lethal cases and brief literature review. Forensic Sci Int. 2016; 265: 96-102. doi: 10.1016/j.forsciint.2016.01.01510.1016/j.forsciint.2016.01.015 https://doi.org/10.1016/j.forsciint.2016.01.015
  13. CascioMJJenKY. Cocaine/levamisole-associated autoimmune syndrome: A disease of neutrophil-mediated autoimmunity. Curr Opin Hematol. 2018; 25(1): 29-36. doi: 10.1016/j. forsciint.2016.01.015 Submit your article to this journal | https://openventio.org/submit-manuscript/10.1016/j.forsciint.2016.01.015 https://doi.org/10.1016/j.forsciint.2016.01.015