A 47‐year‐old female with a history of cocaine and marijuana abuse presented to a New York hospital complaining of diffuse bilateral joint pains for one month duration, worse with movement and applied pressure. Physical exam revealed point tenderness bilaterally at the knees, elbows, distal and proximal interphalangeal joints, as well as left hand swelling with decreased left hand‐grip strength. Laboratory studies were significant for a white blood cell count of 0.6 K/uL, absolute neutrophil count of 200, erythrocyte sedimentation rate of 55 mm/h, urine positive for cocaine and THC, anti‐nuclear antibody of 1:40, double‐stranded DNA of 188 IU/mL and perinuclear anti‐neutrophil cytoplasmic antibody positive. Further questioning revealed she last used cocaine 1 week ago, and that her cocaine was “cut” to enhance her high. Toxicology, rheumatology, and hematology consults conferred that her neutropenia and diffuse arthritis were likely due to levamisole toxicity. With abstinence from cocaine during her hospitalization, her absolute neutrophil count increased and her joint pains were controlled with NSAIDS.
Levamisole, with a short half‐life of 5.6 hours, is an aminothiazole derivative developed in the 1960s as a chemotherapeutic agent and more recently as a veterinary antihelmintic drug. In 1990, it was approved as an adjuvant agent to treat colon cancer but was subsequently withdrawn from the market in 2000 due to agranulocytosis from an unknown mechanism. In the past decade, levamisole has been increasingly used as an adulterant to cocaine, with the DEA reporting that approximately 69% of the cocaine seized in the US in 2009 was laced with levamisole. In rat studies, levamisole has been shown to increase endogenous morphine, codeine, dopamine and serotonin levels in various regions of the brain. The majority of patients with pure cocaine intoxication experience arthralgias initially, but cocaine laced with levamisole has been linked to the presence of antineutrophil cytoplasmic antibodies in the serum, mimicking rheumatologic diseases. While many patients exposed to levamisole present with cutaneous manifestations such as hemorrhagic bullae or skin necrosis, our patient presented only with joint pain and severe leukopenia. The treatment of levamisole‐induced clinical and serologic manifestations is supportive care, with resolution seen in weeks to months with abstinence from further cocaine use.
The high prevalence of levamisole mixed with cocaine mandates that clinicians recognize its associated hematologic and rheumatologic effects. Although patients may present with clinical and serologic manifestations of lupus or polyarteritis nodosa, it is important to recognize that in cocaine users, these findings may actually be due to levamisole. Close outpatient follow‐up is necessary to ensure that these clinical and serologic effects resolve over time in the absence of further cocaine use.
To cite this abstract:Bodner S, Cohen J, Navetta B, Zheng K, Makhnevich A. Cocaine: Old Problem with New Complications. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 352. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/cocaine-old-problem-with-new-complications/. Accessed April 1, 2020.