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Major T, Nagy G, Szabó J, Mózes H, Szűcs G, Szekanecz Z, Szamosi S. Granulomatosis with polyangiitis or its mimic? A case report. J Int Med Res 2024; 52:3000605241237876. [PMID: 38606757 PMCID: PMC11015776 DOI: 10.1177/03000605241237876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/21/2024] [Indexed: 04/13/2024] Open
Abstract
Differentiation between granulomatosis with polyangiitis (GPA) limited to the upper airways and cocaine-induced midline destructive lesion (CIMDL) may be particularly difficult because of their common histopathologic features and antineutrophil cytoplasmic antibody (ANCA) profiles. We herein present a case involving a young woman with an initial diagnosis of GPA based on upper and lower airway manifestations and constitutional symptoms, histopathologic evidence of granulomas, a positive cytoplasmic ANCA indirect immunofluorescent test result, and proteinase 3 positivity by enzyme-linked immunosorbent assay (ELISA). CIMDL was confirmed based on the appearance of a hard palate perforation, positivity for methylecgonine on urine toxicology, a positive perinuclear ANCA indirect immunofluorescent test result, and subsequent human neutrophil elastase (HNE) ANCA positivity by ELISA. Finally, based on the coexistence of CIMDL, constitutional symptoms, and lower airway manifestations, the diagnosis was modified to cocaine-induced GPA mimic. Urine toxicology for cocaine and HNE ELISA are indicated in young patients with GPA who develop limited airway disease to check for the presence of CIMDL and cocaine-/levamisole-induced ANCA-associated vasculitis. Continued abstinence from cocaine is the first-choice therapy for both CIMDL and cocaine-induced GPA mimic.
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Affiliation(s)
- Tamás Major
- Department of Otorhinolaryngology, Heves County Markhot Ferenc Teaching Hospital and Outpatient Clinic, Eger, Hungary
| | - Gábor Nagy
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Judit Szabó
- Department of Pathology, Péterfy Sándor Street Hospital-Policlinic, Budapest, Hungary
| | - Huba Mózes
- Ear-Nose-Throat Department, Emergency County Hospital, Oradea, Romania
| | - Gabriella Szűcs
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Szekanecz
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Szilvia Szamosi
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Turley B, Evans A, Benzio K. Comparative toxicology of syringe exchange and postmortem blood samples in the District of Columbia: Trends and affinity analysis. J Anal Toxicol 2023; 47:588-596. [PMID: 37530762 DOI: 10.1093/jat/bkad052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/23/2023] [Accepted: 08/01/2023] [Indexed: 08/03/2023] Open
Abstract
This cross-sectional analysis aimed to understand the similarities and differences between drugs detected in syringes collected from syringe service providers in the District of Columbia and fatal overdose deaths captured by the State Unintentional Drug Overdose Reporting System. Substance exposures for these fatal and non-fatal drug use outcomes have not been previously compared. Substance distributions were examined and a paired significance test was used to compare changes over time. Affinity analysis was employed to reveal substance co-occurrences. Between September 2020 and September 2022, 1,118 postmortem blood samples (PBSs) and 3,646 syringes exchange samples (SESs) were processed, with fatal overdoses increasing 24.1%. Polysubstance use was more commonly found in postmortem blood (82.5%) than in syringe samples (48.6%). Of samples containing opioids, 94.8% of blood samples and 86.3% of syringes contained fentanyl, fentanyl analogs or fentanyl precursors/metabolites. PBSs had double the frequency of co-occurring stimulants and opioids (43.9%) as SESs (21.8%). Major changes in occurrence frequency over time were found for opioid and stimulant exposure in both groups, especially in the increased occurrence of fluorofentanyl (>400%), methamphetamine (>90%) and xylazine (>60%), while the incidence of fentanyl, heroin and metabolite morphine declined. These results indicate that while fatal use and syringe exchange populations have distinct substance exposures, which may contribute to differences in mortality rate, their substance distributions have similar change magnitudes. This study highlights the utility of using multiple data sources to provide a comprehensive description of drug use patterns and discusses the limitations in reporting data from each source.
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Affiliation(s)
- Ben Turley
- DC Department of Health, 899 North Capitol St NE, Washington, DC 20002, USA
- CDC Foundation, 600 Peachtree St NE #1000, Atlanta, GA 30308, USA
| | - Alexandra Evans
- DC Department of Forensic Sciences, 401 E St SW, Washington, DC 20024, USA
| | - Katharine Benzio
- DC Office of the Chief Medical Examiner, 401 E St SW, Washington, DC 20024, USA
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3
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Mohammed GF, Al-Dhubaibi MS, Bahaj SS, Elneam AIA. Systemic immunotherapy for the treatment of warts: A literature review. J Cosmet Dermatol 2022; 21:5532-5536. [PMID: 36017650 DOI: 10.1111/jocd.15330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/12/2022] [Accepted: 08/23/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Immunotherapy has emerged as a critical therapeutic tool for the treatment of warts. Immunotherapy for warts is currently restricted to recalcitrant lesions. A small number of regimens appear to be extremely effective. Furthermore, there is a scarcity of evidence-based research. OBJECTIVE Furthermore, in the majority of cases, their safety and effectiveness have not been evaluated in double-blind, controlled clinical trials, making the reproducibility of many of the listed treatments difficult to analyze and a possible placebo effect difficult to rule out. METHODS Analyzing and discussing different types of systemic immunotherapy. The different types of immunotherapy for warts are mentioned in this report. RESULTS Systemic immunotherapeutic modalities commonly used in the treatment Echinacea, propolis, oral retinoids, glycyrrhizinic acid, levamisole, cimetidine, and zinc sulfate have all been reported as effective treatment modalities for different types of warts. CONCLUSION Immunotherapy has emerged as one of the most important therapeutic modalities for warts. Such treatment is required not only for recalcitrant or multiple lesions, but also in the majority of treated cases.
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Affiliation(s)
- Ghada Farouk Mohammed
- Department of Dermatology, Venereology and Sexology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | | | - Saleh Salem Bahaj
- Department of Microbiology and Immunology, Faculty of Medicine and Health Sciences, Sana'a University, Sana'a, Yemen
| | - Ahmed Ibrahim Abd Elneam
- Department of Clinical Biochemistry, Department of Basic Medical Sciences, College of Medicine, Shaqra University, Dawadmi, Saudi Arabia.,Molecular Genetics and Enzymology Department, Human Genetics and Genome Research Institute, National Research Center, Cairo, Egypt
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Adegoke O, Zolotovskaya S, Abdolvand A, Daeid NN. Fabrication of a near-infrared fluorescence-emitting SiO2-AuZnFeSeS quantum dots-molecularly imprinted polymer nanocomposite for the ultrasensitive fluorescence detection of levamisole. Colloids Surf A Physicochem Eng Asp 2022. [DOI: 10.1016/j.colsurfa.2022.129013] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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5
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White CM, Browne T, Nafziger AN. Inherent Dangers of Using Non-US Food and Drug Administration-Approved Substances of Abuse. J Clin Pharmacol 2021; 61 Suppl 2:S129-S141. [PMID: 34396559 DOI: 10.1002/jcph.1860] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/17/2021] [Indexed: 12/25/2022]
Abstract
Use of US Food and Drug Administration-approved substances of abuse has innate risks due to pharmacologic and pharmacokinetic properties of the medications, but the risk when using nonapproved drug products is much greater. Unbeknownst to the user, the dose of active ingredients in substances of abuse can vary substantially between different products because of manufacturing practices or improper storage. Even naturally occurring substances of abuse can have extensive dosage variability because of effects of the growing season and conditions, or differences in harvesting, storage, or manufacture of the finished products. Many illicit substances are adulterated, to make up for intentional underdosing or to enhance the effect of the intended active ingredient. These adulterants can be dangerous and produce direct cardiovascular, neurologic, hematologic, or dermatologic reactions or obscure adverse effects. Finally, an illicit substance can be contaminated or substituted for another one during its manufacture, leading to differences in adverse events, adverse event severity, or the drug interaction profile. Substances can be contaminated with microbes that induce infections or heavy metals that can damage organs or cause cancer. This milieu of undisclosed substances can also induce drug interactions. For reasons that are discussed, individuals who use substances of abuse are at increased risk of morbidity or mortality if they develop coronavirus disease 2019. Health professionals who treat patients with acute, urgent events associated with substances of abuse, or those treating the chronic manifestations of addiction, need to appreciate the complex and variable composition of substances of abuse and their potential health effects.
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Affiliation(s)
- C Michael White
- Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA.,HOPES Research Group, UConn and Hartford Hospital, Hartford, Connecticut, USA
| | - Thom Browne
- Rubicon Global Enterprises & Colombo Plan Secretariat, Huachuca City, Arizona, USA
| | - Anne N Nafziger
- Bertino Consulting, Schenectady, New York, USA.,Department of Pharmacy Practice, School of Pharmacy & Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
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Saldana CS, Vyas DA, Wurcel AG. Soft Tissue, Bone, and Joint Infections in People Who Inject Drugs. Infect Dis Clin North Am 2021; 34:495-509. [PMID: 32782098 DOI: 10.1016/j.idc.2020.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Infections are a common complication among people who inject drugs (PWID). Skin and soft tissue infections (SSTI) as well as bone and joint infections comprise a significant source of morbidity and mortality among this population. The appropriate recognition and management of these infections are critical for providers, as is familiarity with harm-reduction strategies. This review provides an overview of the presentation and management of SSTI and bone and joint infections among PWID, as well as key prevention measures that providers can take.
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Affiliation(s)
- Carlos S Saldana
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Darshali A Vyas
- Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Alysse G Wurcel
- Department of Medicine, Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA.
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Midthun KM, Nelson LS, Logan BK. Levamisole-a Toxic Adulterant in Illicit Drug Preparations: a Review. Ther Drug Monit 2021; 43:221-228. [PMID: 33298746 DOI: 10.1097/ftd.0000000000000851] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 11/10/2020] [Indexed: 02/06/2023]
Abstract
ABSTRACT Discovered in the 1960s, the common anthelminthic levamisole has seen widespread use in veterinary applications. Its use rapidly expanded thereafter to include human medical treatments for a variety of acute and chronic disorders. Because of reports of severe adverse effects, the US Food and Drug Administration withdrew levamisole's approval for human use in 2000; however, medical options outside the United States and illicit options worldwide allow continued accessibility to levamisole. The compound is rapidly metabolized in the body, with at least 2 known active metabolites. Levamisole has a broad range of immunomodulatory effects, including both stimulatory and inhibitory effects on immune responses. It is generally well tolerated at therapeutic concentrations, although a variety of autoimmune-related adverse effects have been reported, including agranulocytosis, leukopenia, purpura, and visible necrotized skin tissue. Individuals with levamisole-compromised immune systems are more susceptible to infections, including COVID-19. Since the early 2000's, levamisole has been frequently used as an adulterating agent in illicit street drugs, especially cocaine, fentanyl, and heroin. Although its prevalence has varied over time and geographically, levamisole has been detected in up to 79% of the street supply of cocaine at levels up to 74% by weight. Its presence in illicit drug markets also raises concern over the potential for exposure of children and neonates, although this is supported by only limited anecdotal evidence. Levamisole is not currently included in routine drug testing panels, although a variety of confirmatory testing techniques exist across a range of antemortem and postmortem specimen options. Because of its varying presence in illicit drug markets, both the medical and forensic communities need to be aware of levamisole and its potential impact on toxicological investigations.
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Affiliation(s)
| | - Lewis S Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey; and
| | - Barry K Logan
- NMS Labs, Horsham, Pennsylvania
- Center for Forensic Science Research and Education (CFSRE) at the Fredric Rieders Family Foundation, Willow Grove, Pennsylvania
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Effects of cocaine and levamisole (as adulterant) on the isolated perfused Langendorff heart. Int J Legal Med 2020; 134:1741-1752. [PMID: 32377925 PMCID: PMC7417403 DOI: 10.1007/s00414-020-02300-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 04/14/2020] [Indexed: 01/09/2023]
Abstract
Cocaine-related deaths occur regularly in forensic routine work. In cases in which the detected concentration of cocaine is rather low and other causes of death apart from intoxication can be ruled out, the question arises if adulterants of cocaine might have played a crucial role. In the present study, cardiac effects of cocaine, of the adulterant levamisole and of mixtures of both were evaluated using the isolated perfused Langendorff heart. While exposed to the substances, functional parameters heart rate, left ventricular pressure and coronary flow were documented. Relevant alterations of these parameters were found for cocaine as well as for levamisole. Exposing the hearts to a mixture of both resulted in a combination of these effects; the emergence of new alterations or an obvious aggravation were not detected. Nevertheless, the results imply that the consumption of cocaine adulterated with levamisole bares an increased risk for cardiac complications, especially in the presence of preexisting cardiac pathologies.
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Liu M, Panda SK, Luyten W. Plant-Based Natural Products for the Discovery and Development of Novel Anthelmintics against Nematodes. Biomolecules 2020; 10:biom10030426. [PMID: 32182910 PMCID: PMC7175113 DOI: 10.3390/biom10030426] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/27/2020] [Accepted: 03/02/2020] [Indexed: 12/11/2022] Open
Abstract
Intestinal parasitic nematodes infect approximately two billion people worldwide. In the absence of vaccines for human intestinal nematodes, control of infections currently relies mainly on chemotherapy, but resistance is an increasing problem. Thus, there is an urgent need for the discovery and development of new anthelmintic drugs, especially ones with novel mechanisms of action. Medicinal plants hold great promise as a source of effective treatments, including anthelmintic therapy. They have been used traditionally for centuries and are mostly safe (if not, their toxicity is well-known). However, in most medicinal plants the compounds active against nematodes have not been identified thus far. The free-living nematode C. elegans was demonstrated to be an excellent model system for the discovery of new anthelmintics and for characterizing their mechanism of action or resistance. The compounds discussed in this review are of botanical origin and were published since 2002. Most of them need further studies of their toxicity, mechanisms and structure-activity relationship to assess more fully their potential as drugs.
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Alomar M, Palaian S, Al-Tabakha MM. Pharmacovigilance in perspective: drug withdrawals, data mining and policy implications. F1000Res 2019; 8:2109. [PMID: 32161643 PMCID: PMC7050268 DOI: 10.12688/f1000research.21402.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2019] [Indexed: 12/23/2022] Open
Abstract
Considering that marketed drugs are not free from side effects, many countries have initiated pharmacovigilance programs. These initiatives have provided countries with methods of detection and prevention of adverse drug reactions at an earlier stage, thus preventing harm occurring in the larger population. In this review, examples of drug withdrawals due to effective pharmacovigilance programs have been provided with details. In addition, information concerning data mining in pharmacovigilance, an effective method to assess pharmacoepidemiologic data and detecting signals for rare and uncommon side effects, is also examined, which is a method synchronized with information technology and advanced electronic tools. The importance of policy framework in relation to pharmacovigilance is discussed in detail, and country experiences upon implementation of pharmacovigilance policies is highlighted.
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Affiliation(s)
- Muaed Alomar
- Clinical Sciences Department, Ajman University, Ajman, Ajman, United Arab Emirates
| | - Subish Palaian
- Clinical Sciences Department, Ajman University, Ajman, Ajman, United Arab Emirates
| | - Moawia M Al-Tabakha
- Pharmaceutical Sciences Department, College of Pharmacy and Health Sciences, Ajman University, Ajman, United Arab Emirates
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Gameiro R, Costa S, Barroso M, Franco J, Fonseca S. Toxicological analysis of cocaine adulterants in blood samples. Forensic Sci Int 2019; 299:95-102. [DOI: 10.1016/j.forsciint.2019.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 03/02/2019] [Accepted: 03/04/2019] [Indexed: 11/28/2022]
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Fiorentin TR, Fogarty M, Limberger RP, Logan BK. Determination of cutting agents in seized cocaine samples using GC–MS, GC–TMS and LC–MS/MS. Forensic Sci Int 2019; 295:199-206. [DOI: 10.1016/j.forsciint.2018.12.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 12/14/2018] [Accepted: 12/18/2018] [Indexed: 10/27/2022]
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Fiorentin TR, Krotulski AJ, Martin DM, Browne T, Triplett J, Conti T, Logan BK. Detection of Cutting Agents in Drug‐Positive Seized Exhibits within the United States. J Forensic Sci 2018; 64:888-896. [DOI: 10.1111/1556-4029.13968] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 11/06/2018] [Accepted: 11/06/2018] [Indexed: 01/06/2023]
Affiliation(s)
- Taís R. Fiorentin
- The Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation 2300 Stratford Ave Willow Grove PA 19090
| | - Alex J. Krotulski
- The Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation 2300 Stratford Ave Willow Grove PA 19090
| | - David M. Martin
- Drug Enforcement Administration Educational Foundation 2020 Pennsylvania Ave Washington DC 20006
| | - Thom Browne
- The Colombo Plan 31 Wijerama Mawatha Colombo 7 Sri Lanka
| | - Jeremy Triplett
- Kentucky State Police Central Forensic Laboratory 100 Sower Blv Frankfurt KY 40601
| | - Trisha Conti
- Vermont Forensic Laboratory 45 State Drive Waterbury VT 05671
| | - Barry K. Logan
- The Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation 2300 Stratford Ave Willow Grove PA 19090
- NMS Labs 3701 Welsh Road Willow Grove PA 19090
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Dartevel A, Chaigne B, Moachon L, Grenier F, Dupin N, Guillevin L, Bouillet L, Mouthon L. Levamisole-induced vasculopathy: A systematic review. Semin Arthritis Rheum 2018; 48:921-926. [PMID: 30166200 DOI: 10.1016/j.semarthrit.2018.07.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 06/27/2018] [Accepted: 07/23/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To characterize levamisole-induced vasculopathy. METHODS We performed a systematic review searching MEDLINE for articles published from 1972 to 2016. RESULTS We retrieved 357 references and abstracts and selected 111 articles. Levamisole-induced vasculopathy was reported in 192 patients, with a female predominance (n = 122, 63.5%). Median [interquartile range] age was 44 [38-50]. Skin was the most frequently involved organ (n = 182, 94.8%). Cutaneous lesions were mostly on the face (n = 136, 70.8%), especially the ears. Purpura (n = 131, 68.2%) was the most reported cutaneous lesion. Organ involvement included acute renal failure (n = 24, 12.5%), and pulmonary involvement (n = 20, 10.4%). Anti-neutrophil cytoplasmic antibodies (ANCAs) were found in 167/178 patients (93.8%), with both anti-myeloperoxydase and anti-proteinase 3 specificity reported in 51/118 patients (43.2%). Anti-phospholipid (APL) antibodies were found in 93/137 patients (67.9%). Leukopenia was detected in 69/138 patients (50%). Skin biopsies identified vasculitis and thrombotic vasculopathy in 73/148 (49.3%) and 62/148 (41.9%) patients, respectively. The outcome was favourable in 116/134 patients (86.6%), but relapses were reported in 33 (28.4%), mainly on levamisole re-exposure. CONCLUSION Levamisole-induced vasculopathy is characterized by a female predominance, skin involvement, ANCA and/or APL antibody positivity, leukopenia, vasculitis or vascular thrombotic histological lesions, and despite possible systemic involvement, a favourable outcome with levamisole interruption.
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Affiliation(s)
- Anaïs Dartevel
- Service de Médecine Interne, hôpital Cochin, Centre de Référence pour les maladies systémiques autoimmunes rares d'Ile de France, DHU Authors (Autoimmune and Hormonal Diseases), Université Paris Descartes, Sorbonne Paris Cité, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; Service de Médecine Interne, Centre national de référence des angiœdème (CREAK), Universités des Alpes-Grenoble 1, 38041 Grenoble, France
| | - Benjamin Chaigne
- Service de Médecine Interne, hôpital Cochin, Centre de Référence pour les maladies systémiques autoimmunes rares d'Ile de France, DHU Authors (Autoimmune and Hormonal Diseases), Université Paris Descartes, Sorbonne Paris Cité, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Laurence Moachon
- Service de Pharmacologie, Hôpital Cochin, AP-HP, and Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Florian Grenier
- Service de médecine légale, Universités des Alpes-Grenoble 1, 38041 Grenoble, France
| | - Nicolas Dupin
- Service de Dermatologie, Hôpital Cochin, AP-HP, and Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Loïc Guillevin
- Service de Médecine Interne, hôpital Cochin, Centre de Référence pour les maladies systémiques autoimmunes rares d'Ile de France, DHU Authors (Autoimmune and Hormonal Diseases), Université Paris Descartes, Sorbonne Paris Cité, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Laurence Bouillet
- Service de Médecine Interne, Centre national de référence des angiœdème (CREAK), Universités des Alpes-Grenoble 1, 38041 Grenoble, France
| | - Luc Mouthon
- Service de Médecine Interne, hôpital Cochin, Centre de Référence pour les maladies systémiques autoimmunes rares d'Ile de France, DHU Authors (Autoimmune and Hormonal Diseases), Université Paris Descartes, Sorbonne Paris Cité, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.
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Knuth M, Temme O, Daldrup T, Pawlik E. Analysis of cocaine adulterants in human brain in cases of drug-related death. Forensic Sci Int 2018; 285:86-92. [PMID: 29454838 DOI: 10.1016/j.forsciint.2018.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 01/29/2018] [Accepted: 02/03/2018] [Indexed: 11/29/2022]
Abstract
For different reasons, street cocaine is often diluted with pharmacologically active substances, the so-called adulterants such as levamisole or hydroxyzine. A controversial debate exists currently on the uptake of adulterants from cocaine preparations and drug-related death. Previous research convincingly argues that serious adverse side effects that affect the central nervous and cardiovascular systems can be a consequence of adulterated cocaine. AIMS Having identified the presence of adulterants in lung tissue and blood, the concentrations of these substances in brain, an important target location, was of interest. This provides an opportunity to assess their role in cases of drug-related deaths. MATERIALS AND METHODS We developed and validated a method for the analysis of cocaine, two cocaine metabolites and six adulterants, which can typically be found in cocaine preparations, and one adulterant metabolite in brain tissue by gas chromatography-mass spectrometry (GC-MS)1. Ten brain samples which were tested positive for cocaine were analyzed. The homogenized brain tissue was embedded into drying paper for protein precipitation. During a subsequent solid-phase extraction (SPE), the eluate and one of the wash fractions were collected. After derivatization with N-Methyl-N-(trimethylsilyl)trifluoroacetamide (MSTFA) in pyridine and isooctane, the extracts were analyzed by GC-MS. RESULTS AND DISCUSSION The method was fully validated for cocaine (COC), benzoylecgonine (BZE), ecgonine methyl ester (EME), diltiazem (DIL), hydroxyzine (HYD), and levamisole (LEV) and partly validated for cetirizine (CET), lidocaine (LID), phenacetin (PHE), and procaine (PRO) in brain material. By analyzing post-mortem brain tissue of ten cocaine users, LEV, LID, and HYD as well as PHE were identified in contrast to DIL, PRO, and the HYD metabolite CET. HYD and LEV were found in moderate to high concentrations in some cases. Therefore, it cannot be excluded that they have caused adverse side effects. CONCLUSION Because adulterants can potentially affect the central nervous and cardiac systems, it is likely that they enhance COC toxicity.
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Affiliation(s)
- Marianne Knuth
- Institute of Legal Medicine, University Hospital Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany.
| | - Oliver Temme
- Institute of Legal Medicine, University Hospital Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Thomas Daldrup
- Institute of Legal Medicine, University Hospital Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Evelyn Pawlik
- Institute of Legal Medicine, University Hospital Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
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Le Garff E, Tournel G, Becquart C, Cottencin O, Dupin N, Delaporte E, Hedouin V. Extensive Necrotic Purpura in Levamisole-Adulterated Cocaine Abuse - A Case Report. J Forensic Sci 2016; 61:1681-1685. [PMID: 27500987 DOI: 10.1111/1556-4029.13176] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 01/26/2016] [Accepted: 01/30/2016] [Indexed: 11/28/2022]
Abstract
Levamisole, which is used as an adulterated compound of cocaine, is currently being seen year after year in cocaine intoxication. For a few cases in the last decade, necrotic purpura and neutropenia after levamisole/cocaine intoxication have been described in the medical community. Herein, we present an original case of levamisole intoxication of a 40-year-old woman who smoked heroin and cocaine few during a month. She rapidly presented an extensive necrotic purpura of the nose, cheeks and extremities (lower and upper), and immunologic reactions (positive anti-MPO and anti-HNE). Levamisole was detected on hairs with ultra-high performance liquid chromatography and tandem mass spectrometry. The case reports also a probable cocaine supplier deceit, which bring pure drug for hospital investigation after the intoxication of his client. The intoxicated woman had survived with several skin and chronic pain complications. That case recalls the knowledge about levamisole with a short review of the forensic literature.
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Affiliation(s)
- Erwan Le Garff
- Service de Médecine Légale, CHU Lille, University Lille, UTML 7367, F-59000, Lille, France
| | - Gilles Tournel
- Service de Médecine Légale, CHU Lille, University Lille, UTML 7367, F-59000, Lille, France.,Service de toxicologie, CHU Lille, University Lille, F-59000, Lille, France
| | - Coralie Becquart
- Service de dermatologie, CHU Lille, University Lille, F-59000, Lille, France
| | - Olivier Cottencin
- ScaLab CNRS UMR 9193, Service d'addictologie, CHU Lille, University Lille, F-59000, Lille, France
| | - Nicolas Dupin
- Service de dermatologie, CHU Cochin, Rue du Faubourg St Jacques, 75014, Paris, France
| | - Emmanuel Delaporte
- Service de dermatologie, CHU Lille, University Lille, F-59000, Lille, France
| | - Valéry Hedouin
- Service de Médecine Légale, CHU Lille, University Lille, UTML 7367, F-59000, Lille, France
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Levamisole-adulterated cocaine: Two fatal case reports and evaluation of possible cocaine toxicity potentiation. Forensic Sci Int 2016; 265:103-6. [DOI: 10.1016/j.forsciint.2016.01.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 12/30/2015] [Accepted: 01/02/2016] [Indexed: 12/28/2022]
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Imbernón-Moya A, Chico R, Aguilar-Martínez A. [Cutaneous and mucosal manifestations associated with cocaine use]. Med Clin (Barc) 2016; 146:544-9. [PMID: 27033438 DOI: 10.1016/j.medcli.2016.02.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 02/03/2016] [Accepted: 02/04/2016] [Indexed: 10/22/2022]
Abstract
Complications due to cocaine are a public health problem. The typical cutaneous disease is leukocytoclastic vasculitis and/or thrombotic vasculopathy affecting mainly the ears. No intense systemic involvement is usually present, but there may be several cutaneous, mucosal and systemic manifestations. Other findings associated as arthralgia, neutropaenia or agranulocytosis, low titer positive antinuclear antibodies, antiphospholipid antibody positivity and neutrophil cytoplasmic antibodies against multiple antigens help the diagnosis. This disease requires a clinical suspicion with a clinical history, a complete physical examination and a broad differential diagnosis for an early and correct diagnosis. The course is usually self-limited. In most cases the only treatment is to discontinue the use of cocaine associated with symptomatic treatment, no proven benefit of systemic corticosteroids.
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Affiliation(s)
- Adrián Imbernón-Moya
- Servicio de Dermatología, Hospital Universitario Severo Ochoa, Leganés, Madrid, España.
| | - Ricardo Chico
- Servicio de Dermatología, Hospital Universitario Severo Ochoa, Leganés, Madrid, España
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19
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20
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Wurcel AG, Merchant EA, Clark RP, Stone DR. Emerging and Underrecognized Complications of Illicit Drug Use. Clin Infect Dis 2015; 61:1840-9. [PMID: 26270683 DOI: 10.1093/cid/civ689] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 07/30/2015] [Indexed: 12/25/2022] Open
Abstract
Illicit drug use can result in a wide range of medical complications. As the availability, synthesis, and popularity of illicit drugs evolve over time, new syndromes associated with their use may mimic infections. Some of these symptoms are anticipated drug effects, and others are complications of adulterants mixed with drugs or complications from the method of using drugs. Some illicit drugs are associated with rare infections, which are difficult to diagnosis with standard microbiological techniques. The goal of this review is to orient a wide range of clinicians-including general practitioners, emergency medicine providers, and infectious diseases specialists-to complications of illicit drug use that may be underrecognized. Improving awareness of infectious and noninfectious complications of illicit drug can expedite diagnosis and medical treatment of persons who use drugs and facilitate targeted harm reduction counseling to prevent future complications.
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Affiliation(s)
- Alysse G Wurcel
- Department of Geographic Medicine and Infectious Diseases Department of Public Health and Community Medicine, Tufts University School of Medicine
| | | | - Roger P Clark
- Department of Geographic Medicine and Infectious Diseases Brigham and Women's Faulkner Hospital, Boston, Massachusetts
| | - David R Stone
- Department of Geographic Medicine and Infectious Diseases
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Pawlik E, Mahler H, Hartung B, Plässer G, Daldrup T. Drug-related death: Adulterants from cocaine preparations in lung tissue and blood. Forensic Sci Int 2015; 249:294-303. [DOI: 10.1016/j.forsciint.2015.02.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 01/21/2015] [Accepted: 02/02/2015] [Indexed: 11/25/2022]
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Tallarida CS, Tallarida RJ, Rawls SM. Levamisole enhances the rewarding and locomotor-activating effects of cocaine in rats. Drug Alcohol Depend 2015; 149:145-50. [PMID: 25683823 PMCID: PMC4447121 DOI: 10.1016/j.drugalcdep.2015.01.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 01/24/2015] [Accepted: 01/25/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND The Drug Enforcement Agency estimates that 80% of cocaine seized in the United States contains the veterinary pharmaceutical levamisole (LVM). One problem with LVM is that it is producing life-threatening neutropenia in an alarming number of cocaine abusers. The neuropharmacological profile of LVM is also suggestive of an agent with modest reinforcing and stimulant effects that could enhance cocaine's addictive effects. METHODS We tested the hypothesis that LVM (ip) enhances the rewarding and locomotor stimulant effects of cocaine (ip) using rat conditioned place preference (CPP) and locomotor assays. Effects of LVM by itself were also tested. RESULTS LVM (0-10 mg/kg) produced CPP at 1mg/kg (P<0.05) and locomotor activation at 5mg/kg (P < 0.05). For CPP combination experiments, a statistically inactive dose of LVM (0.1 mg/kg) was administered with a low dose of cocaine (2.5 mg/kg). Neither agent produced CPP compared to saline (P > 0.05); however, the combination of LVM and cocaine produced enhanced CPP compared to saline or either drug by itself (P < 0.01). For locomotor experiments, the same inactive dose of LVM (0.1mg/kg, ip) was administered with low (10 mg/kg) and high doses (30 mg/kg) of cocaine. LVM (0.1 mg/kg) enhanced locomotor activation produced by 10mg/kg of cocaine (P < 0.05) but not by 30 mg/kg (P>0.05). CONCLUSIONS LVM can enhance rewarding and locomotor-activating effects of low doses of cocaine in rats while possessing modest activity of its own.
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Affiliation(s)
- Christopher S Tallarida
- Center for Substance Abuse Research, Temple University School of Medicine, Philadelphia, PA, USA; Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, USA
| | - Ronald J Tallarida
- Center for Substance Abuse Research, Temple University School of Medicine, Philadelphia, PA, USA; Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, USA
| | - Scott M Rawls
- Center for Substance Abuse Research, Temple University School of Medicine, Philadelphia, PA, USA; Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, USA.
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Jantan I, Ahmad W, Bukhari SNA. Plant-derived immunomodulators: an insight on their preclinical evaluation and clinical trials. FRONTIERS IN PLANT SCIENCE 2015; 6:655. [PMID: 26379683 PMCID: PMC4548092 DOI: 10.3389/fpls.2015.00655] [Citation(s) in RCA: 184] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 08/07/2015] [Indexed: 05/17/2023]
Abstract
The phagocyte-microbe interactions in the immune system is a defense mechanism but when excessively or inappropriately deployed can harm host tissues and participate in the development of different non-immune and immune chronic inflammatory diseases such as autoimmune problems, allergies, some rheumatoid disorders, cancers and others. Immunodrugs include organic synthetics, biological agents such as cytokines and antibodies acting on single targets or pathways have been used to treat immune-related diseases but with limited success. Most of immunostimulants and immunosuppressants in clinical use are the cytotoxic drugs which possess serious side effects. There is a growing interest to use herbal medicines as multi-component agents to modulate the complex immune system in the prevention of infections rather than treating the immune-related diseases. Many therapeutic effects of plant extracts have been suggested to be due to their wide array of immunomodulatory effects and influence on the immune system of the human body. Phytochemicals such as flavonoids, polysaccharides, lactones, alkaloids, diterpenoids and glycosides, present in several plants, have been reported to be responsible for the plants immunomodulating properties. Thus the search for natural products of plant origin as new leads for development of potent and safe immunosuppressant and immunostimulant agents is gaining much major research interest. The present review will give an overview of widely investigated plant-derived compounds (curcumin, resveratrol, epigallocatechol-3-gallate, quercetin, colchicine, capsaicin, andrographolide, and genistein) which have exhibited potent effects on cellular and humoral immune functions in pre-clinical investigations and will highlight their clinical potential.
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Affiliation(s)
- Ibrahim Jantan
- *Correspondence: Ibrahim Jantan, Drug and Herbal Research Centre, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia,
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Determination of levamisole and tetramisole in seized cocaine samples by enantioselective high-performance liquid chromatography and circular dichroism detection. J Chromatogr A 2014; 1363:150-4. [DOI: 10.1016/j.chroma.2014.07.069] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 07/11/2014] [Accepted: 07/22/2014] [Indexed: 11/19/2022]
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Tallarida CS, Egan E, Alejo GD, Raffa R, Tallarida RJ, Rawls SM. Levamisole and cocaine synergism: a prevalent adulterant enhances cocaine's action in vivo. Neuropharmacology 2014; 79:590-5. [PMID: 24440755 DOI: 10.1016/j.neuropharm.2014.01.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 01/02/2014] [Accepted: 01/04/2014] [Indexed: 01/17/2023]
Abstract
Levamisole is estimated by the Drug Enforcement Agency (DEA) to be present in about 80% of cocaine seized in the United States and linked to debilitating, and sometimes fatal, immunologic effects in cocaine abusers. One explanation for the addition of levamisole to cocaine is that it increases the amount of product and enhances profits. An alternative possibility, and one investigated here, is that levamisole alters cocaine's action in vivo. We specifically investigated effects of levamisole on cocaine's stereotypical and place-conditioning effects in an established invertebrate (planarian) assay. Acute exposure to levamisole or cocaine produced concentration-dependent increases in stereotyped movements. For combined administration of the two agents, isobolographic analysis revealed that the observed stereotypical response was enhanced relative to the predicted effect, indicating synergism for the interaction. In conditioned place preference (CPP) experiments, cocaine produced a significant preference shift; in contrast, levamisole was ineffective at all concentrations tested. For combination experiments, a submaximal concentration of cocaine produced CPP that was enhanced by inactive concentrations of levamisole, indicating synergism. The present results provide the first experimental evidence that levamisole enhances cocaine's action in vivo. Most important is the identification of synergism for the levamisole/cocaine interaction, which now requires further study in mammals.
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Affiliation(s)
- Christopher S Tallarida
- Center for Substance Abuse Research, Temple University School of Medicine, Philadelphia, PA, USA; Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, USA
| | - Erin Egan
- Center for Substance Abuse Research, Temple University School of Medicine, Philadelphia, PA, USA; Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, USA
| | - Gissel D Alejo
- Center for Substance Abuse Research, Temple University School of Medicine, Philadelphia, PA, USA; Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, USA
| | - Robert Raffa
- Center for Substance Abuse Research, Temple University School of Medicine, Philadelphia, PA, USA; Department of Pharmaceutical Sciences, Temple University School of Pharmacy, Philadelphia, PA, USA
| | - Ronald J Tallarida
- Center for Substance Abuse Research, Temple University School of Medicine, Philadelphia, PA, USA; Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, USA
| | - Scott M Rawls
- Center for Substance Abuse Research, Temple University School of Medicine, Philadelphia, PA, USA; Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, USA.
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