Cocaine Levamisole Toxicity

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Diagnosis Synopsis

Cocaine Levamisole Toxicity : Cocaine contaminated with levamisole has been detected in the United States since 2003, and the incidence of toxicity caused by this contamination has been increasing rapidly since 2008. Use of cocaine that has been adulterated with levamisole can lead to a constellation of symptoms including agranulocytosis, neutropenia, and a vasculitis-like purpuric tender skin eruption. The most common sites of purpura are the external ears and cheeks. The purpura is generally followed by skin necrosis, but resolves several weeks after cessation of cocaine use. Recurrent use of contaminated cocaine generally results in recurrent skin eruptions.

Necrotic crusted plaques of the ear.

Concomitant symptoms of arthralgias, fever, and mouth pain have been reported.

The CDC estimates that approximately 70% of cocaine in the United States may be contaminated with levamisole. Toxicity induced by levamisole seems to affect all ages and both genders equally depending on cocaine use. The cocaine can be either smoked as crack cocaine or snorted. Some analyses have revealed up to 10% contamination of individual cocaine products.

Because levamisole is difficult to test for and because other treatable causes of vasculitis may be present, levamisole-induced toxicity is a diagnosis of exclusion. Several published cases have had concurrent or preceding medical histories that involve both chronic and acute infections as well as signs of chronic autoimmune disease. Other cases have had absolutely no preceding medical history.

Since neutropenia is a common presenting sign of this toxicity, bacterial or fungal infections may be presenting features of levamisole toxicity.

Look For

Purpuric plaque on the nose.

Somewhat tender purpuric macules and papules on the helix of the ear or the cheeks. Retiform or stellate purpura on the trunk and extremities that can progress to bullae. Very early, the purpura may be preceded by erythematous macules. Progression of the purpura to necrosis and crusting eschars is common before resolution.

Dark Skin Patient Considerations
In dark-skinned individuals, the rash may present with deep red to brown or purple macules and papules. Purpura is difficult to detect in extremely dark.

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