Manasa Enja, M.D., Suneela Cherlopalle, M.D., Melanie Lippmann, M.D., Steven Lippmann, M.D.
         
Cocaine is a frequent drug of abuse and a common precipitant of health emergencies. Recently, cocaine has become an even more dangerous public health concern since being adulterated by the addition of levamisole.
 
It is hard to detect levamisole when mixed with cocaine; the addition of levamisole adds to the volume and appears to augment cocaine’s stimulant effects. However, this agent often causes serious toxicity, which includes a vasculitic effect in the body, especially at the skin, bone marrow, lungs, kidneys, and vascular system. Such a drug reaction can be fatal.
 
Initially, users may experience a generalized flu-like syndrome. Cutaneous findings vary from mild skin rashes to severe necrosis. These lesions can appear anywhere, but are most common on the limbs, trunk, face and ears, especially at the margins of the pinna. Neutropenia or agranulocytosis with infection are additional dangers.
 
Physicians must be alert at detecting levamisole toxicity in cocaine users who have a cutaneous eruption, neutropenia, or signs of a vasculitis. Significant hematologic, nephrologic, and/or pulmonary compromise may occur. Laboratory confirmation of levamisole must be performed as early as possible because the drug has a short duration of action.
 
Treatment is supportive, but in serious cases might mandate antibiotics, burn therapies with debridement, and other surgical or medical interventions. Stopping the offending agent and preventing reintroduction is critical.
 
Beyond medical interventions, patients must be educated about the risks involved and danger of reoccurrence. In every case, offer and encourage those affected to undergo drug-abstinence via substance-abuse treatment.
 
Suggested readings:
1.    Nolan AL, Jen KY. Pathologic manifestations of levamisole-adulterated cocaine exposure. Diagnostic Pathology. 2015; 10:48.
2.    Hofmaier T, Luf A, Seddik A, Stockner T, Holy M, Freissmuth M, Ecker GF,Schmid R, Sitte HH, Kudlacek O. Aminorex, a metabolite of the cocaine adulterant levamisole, exerts amphetamine like actions at monoamine transporters. Neurochemistry International. 2014; 73:32-41.
3.    Chung C, Tumeh PC, Birnbaum R, Tan BH, Sharp L, McCoy E, Mercurio MG, Craft N. Characteristic purpura of the ears, vasculitis, and neutropenia–a potential public health epidemic associated with levamisole-adulterated cocaine. Journal of the American Academy of Dermatology. 2011; 65(4):722-725.