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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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Marquez J, Aguirre L, Muñoz C, Echeverri A, Restrepo M, Pinto LF. Cocaine-Levamisole-Induced Vasculitis/Vasculopathy Syndrome. Curr Rheumatol Rep 2017; 19:36. [DOI: 10.1007/s11926-017-0653-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Imbernón-Moya A, Chico R, de la Hera I, Gallego-Valdés MÁ. Leukocytoclastic vasculitis related to cocaine-adulterated levamisole. ACTAS DERMO-SIFILIOGRAFICAS 2016; 107:795-797. [PMID: 27365279 DOI: 10.1016/j.ad.2016.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 04/06/2016] [Accepted: 04/08/2016] [Indexed: 10/21/2022] Open
Affiliation(s)
- A Imbernón-Moya
- Servicios de Dermatologia, del Hospital Universitario Severo Ochoa, Avda. de Orellana s/n. 28911 - Leganés (Madrid), Spain.
| | - R Chico
- Servicios de Dermatologia, del Hospital Universitario Severo Ochoa, Avda. de Orellana s/n. 28911 - Leganés (Madrid), Spain
| | - I de la Hera
- Servicios de Dermatologia, del Hospital Universitario Severo Ochoa, Avda. de Orellana s/n. 28911 - Leganés (Madrid), Spain
| | - M Á Gallego-Valdés
- Servicios de Dermatologia, del Hospital Universitario Severo Ochoa, Avda. de Orellana s/n. 28911 - Leganés (Madrid), Spain
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Imbernón-Moya A, Chico R, de la Hera I, Gallego-Valdés M. Leukocytoclastic vasculitis related to cocaine-adulterated levamisole. ACTAS DERMO-SIFILIOGRAFICAS 2016. [DOI: 10.1016/j.adengl.2016.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Torregrosa Calatayud JL, Garcías Ladaria J, De Unamuno Bustos B, Zaragoza Ninet V, Alegre De Miquel V. Retiform purpura caused by the use of cocaine, that was probably adulterated with levamisole. Ann Dermatol 2015; 27:117-9. [PMID: 25673953 PMCID: PMC4323595 DOI: 10.5021/ad.2015.27.1.117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 01/23/2014] [Accepted: 04/27/2014] [Indexed: 11/08/2022] Open
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Lawrence LA, Jiron JL, Lin HS, Folbe AJ. Levamisole-adulterated cocaine induced skin necrosis of nose, ears, and extremities: Case report. ALLERGY & RHINOLOGY 2015; 5:132-6. [PMID: 25565048 PMCID: PMC4275458 DOI: 10.2500/ar.2014.5.0101] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Levamisole is an immunomodulatory and antihelminthic drug, previously removed from the United States market, and now estimated to be present in the vast majority of cocaine distributed in the United States. Levamisole-adulterated cocaine (LAC) exposure can result in neutropenia, thrombocytopenia, and vasculitis with a predilection for subsites of the face. The objective of this review is to increase awareness among otolaryngologists of the manifestations of LAC exposure. We present the case of a 33-year-old woman with a history of cocaine use, consulted for purpuric, necrotic lesions of the nose, cheeks, and ears, with accompanying leukopenia, thrombocytopenia, and positive antineutrophil cytoplasmic antibodies (ANCA). The effects of levamisole are immune mediated, with antibodies directed against neutrophils causing neutropenia, and vasculitis caused by antibody deposition or secondary to induction of antiphospholipid antibodies causing thrombosis. LAC exposure can be differentiated from other similar appearing pathologies by evaluating serology for specific ANCA. The most important treatment is cessation of cocaine use, which most often results in complete resolution of symptoms. Awareness of the presentation, complications, and treatment of LAC exposure may be especially important for otolaryngologists, who may be one of the firsts to evaluate an affected patient.
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Affiliation(s)
- Lauren A Lawrence
- Department of Otolaryngology, Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, USA
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Auffenberg C, Rosenthal LJ, Dresner N. Levamisole: A Common Cocaine Adulterant with Life-Threatening Side Effects. PSYCHOSOMATICS 2013; 54:590-3. [DOI: 10.1016/j.psym.2013.02.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2012] [Revised: 02/19/2013] [Accepted: 02/20/2013] [Indexed: 10/26/2022]
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Magliocca KR, Coker NA, Parker SR. The head, neck, and systemic manifestations of levamisole-adulterated cocaine use. J Oral Maxillofac Surg 2013; 71:487-92. [PMID: 23298805 DOI: 10.1016/j.joms.2012.10.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 10/29/2012] [Indexed: 11/26/2022]
Abstract
Systemic complications of levamisole-adulterated cocaine (LAC) use have recently been described. The objective of this review is to increase awareness of these manifestations among oral and maxillofacial surgeons. LAC exposure through inhalation, nasal insufflation, or injection can induce cutaneous vasculopathy and hematologic abnormalities such as neutropenia or agranulocytosis. Unlike other vasculopathies involving the skin, LAC-induced vascular injury frequently manifests with purpuric and necrotic lesions that involve the face and ears. Oral manifestations have also been reported but are not yet well characterized. The aforementioned hematologic manifestations are not uncommon, and patients exposed to LAC are potentially at higher risk for infectious complications. When manifestations of LAC affect the head, neck, and oral cavity, oral and maxillofacial surgeons may be the first providers to encounter the patient. Early recognition of the clinical signs and laboratory abnormalities will better allow for distinguishing LAC-related effects from various clinical mimics, will facilitate appropriate patient management, and may further contribute to the understanding of the biological effects of LAC.
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Affiliation(s)
- Kelly R Magliocca
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA 30322, USA.
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Metwally O, Hamidi M, Townsend L, Abualula H, Zaitoun A, Lall T. The Cocaine Trail: Levamisole-Induced Leukocytoclastic Vasculitis in a Cocaine User. Subst Abus 2013; 34:75-7. [DOI: 10.1080/08897077.2012.718318] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Phillips KA, Hirsch GA, Epstein DH, Preston KL. Cardiac complications of unwitting co-injection of quinine/quinidine with heroin in an intravenous drug user. J Gen Intern Med 2012; 27:1722-5. [PMID: 22592353 PMCID: PMC3509315 DOI: 10.1007/s11606-012-2089-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Revised: 03/26/2012] [Accepted: 04/11/2012] [Indexed: 11/28/2022]
Abstract
Adulterants "cut into" street heroin are common and often not detected by standard urine toxicology screening; however, their unwitting co-injection may have clinical consequences. We report a case of accelerated atrioventricular junctional arrhythmia that we determined to have been caused by quinine/quinidine cut into heroin. While identification and discontinuation of the offending agent helps confirm the diagnosis and is the treatment of choice, this is often complicated by the individual's dependence on the street drug in which the adulterant is mixed. This case highlights the need for clinicians to be aware of common adulterants, to know how to test for them, and to consider them as possible causes of medical complications in individuals who use drugs.
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Affiliation(s)
- Karran A Phillips
- National Institute on Drug Abuse, Intramural Research Program, National Institutes of Health, 251 Bayview Blvd, Bldg BRC, Suite 200, Baltimore, MD 21224, USA.
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Gulati S, Donato AA. Lupus anticoagulant and ANCA associated thrombotic vasculopathy due to cocaine contaminated with levamisole: a case report and review of the literature. J Thromb Thrombolysis 2012; 34:7-10. [PMID: 22437653 DOI: 10.1007/s11239-012-0711-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
A 2010 US report recently detected the presence of levamisole in greater than 77 % of seized cocaine samples. A syndrome of retiform purpura, often involving ears and flanks, with vasculopathy or vasculitis on biopsy, associated with anti-nuclear cytoplasmic antibodies as well as antiphospholipid antibodies, previously associated with therapeutic use of levamisole has now re-emerged, and is associated with cocaine adulterated with levamisole. Patients with this unusual constellation of signs and laboratory findings should be questioned about exposure to cocaine.
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Affiliation(s)
- Shuchi Gulati
- Department of Internal Medicine, The Reading Hospital and Medical Center, 6th Avenue and Spruce Street, West Reading, PA 19611, USA.
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Flores-Suárez LF. Antineutrophil cytoplasm autoantibodies: usefulness in rheumatology. REUMATOLOGIA CLINICA 2012; 8:351-7. [PMID: 22673387 DOI: 10.1016/j.reuma.2012.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 03/17/2012] [Indexed: 01/14/2023]
Abstract
The primary vasculitidies are complex diseases with varied clinical manifestations, which may be common to those present in multiple diseases. The antineutrophil cytoplasm autoantibodies (ANCA) led to a revolution in the diagnosis and research of these diseases, being the first and so far, the only biomarkers for three of these diseases, which affect small caliber vessels. From their description, much progress has been made, but there are still gray or misunderstood areas regarding their best use in the clinic. This can lead to errors as making a positive test synonym for vasculitis, or to overestimation of its importance. This review will address aspects such as nomenclature, employment in the diagnosis and monitoring of vasculitis, their presence in other diseases, their methods of detection, and finally, some comments on other potential biomarkers in vasculitis.
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Affiliation(s)
- Luis Felipe Flores-Suárez
- Clínica de Vasculitis Sistémicas Primarias, Instituto Nacional de Enfermedades Respiratorias, México D.F., México.
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Lee KC, Ladizinski B, Federman DG. Complications associated with use of levamisole-contaminated cocaine: an emerging public health challenge. Mayo Clin Proc 2012; 87:581-6. [PMID: 22677078 PMCID: PMC3498128 DOI: 10.1016/j.mayocp.2012.03.010] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 03/21/2012] [Accepted: 03/27/2012] [Indexed: 10/28/2022]
Abstract
Levamisole is an immunomodulatory agent that was used to treat various cancers before being withdrawn from the United States market in 2000 because of adverse effects. Levamisole is currently approved as an antihelminthic agent in veterinary medicine, but is also being used illicitly as a cocaine adulterant. Potential complications associated with use of levamisole-laced cocaine include neutropenia, agranulocytosis, arthralgias, retiform purpura, and skin necrosis. Treatment is primarily supportive, and skin lesions typically resolve with cessation of cocaine use. The incidence of hospitalizations related to use of levamisole-contaminated cocaine continues to increase and clinicians should be aware of the more common clinical manifestations.
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Affiliation(s)
- Kachiu C. Lee
- Department of Dermatology, Brown University, Providence, RI
| | - Barry Ladizinski
- Department of Dermatology, Duke University Medical Center, Durham, NC
| | - Daniel G. Federman
- Department of Internal Medicine, VA Connecticut Healthcare System, West Haven
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Larocque A, Hoffman RS. Levamisole in cocaine: unexpected news from an old acquaintance. Clin Toxicol (Phila) 2012; 50:231-41. [PMID: 22455354 DOI: 10.3109/15563650.2012.665455] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Levamisole is a pharmaceutical with anthelminthic and immunomodulatory properties that was previously used in both animals and humans to treat inflammatory conditions and cancer. Levamisole has been identified as a cocaine adulterant in the United States since 2003. By 2009, the United States Drug Enforcement Administration (DEA) estimated that 69% of the cocaine seized contained levamisole. The first case reports of complications related to levamisole in cocaine users were published in 2009. The objectives of this article are to review the literature regarding the full spectrum of possible complications related to levamisole use for medical purposes, to review the current scope of levamisole-induced complications in cocaine users and to discuss the pharmacological properties that might explain the motivation behind the large-scale adulteration of cocaine with levamisole. Literature review revealed that significant complications were quickly reported when levamisole was used in inflammatory conditions. By 1976, several cases of leukopenia and agranulocytosis were reported. Recurrence with re-exposure was well described and agranulocytosis spontaneously reversed upon discontinuation of therapy. Vasculitis secondary to levamisole treatment was first reported in 1978 and mostly manifests as leukocytoclastic vasculitis, cutaneous necrotising vasculitis and thrombotic vasculopathy without vasculitis. These findings typically, but not invariably, involve the ear lobes. Discontinuation of levamisole therapy was again a critical part of the treatment. Various neurological side effects were described with levamisole therapy, the most concerning complication being multifocal inflammatory leukoencephalopathy (MIL). Literature review identified 203 unique cases of complications in cocaine users that can be attributed to levamisole adulteration. The two principal complications reported are haematological (140 cases of neutropenia) and dermatological (84 cases). Even though these complications can occur in isolation, many cases displayed both simultaneously. No formal case of leukoencephalopathy in the setting of cocaine use has been reported so far. A striking phenomenon is the apparent high level of recurrence (27.1%) of symptoms in cocaine users after re-exposure to cocaine that is presumably adulterated. The importance of accurately identifying levamisole-induced complications is therefore critical for symptomatic patients as discontinuation of exposure is fundamental and as a correct diagnosis prevents unnecessary and potentially dangerous use of other treatment modalities like powerful immunosuppressive therapy. Literature review suggests that levamisole might have the advantages of enhancing noradrenergic neurotransmission by inhibiting reuptake, by inhibiting MAO and/or COMT, by acting on ganglionic nicotinic receptors and by being partially metabolized into an amphetamine-like compound. It could also increase endogenous opioids and increase dopamine concentration in the cerebral reward pathway. These potential effects make levamisole an interesting choice as a cocaine adulterant. It seems unlikely that levamisole use as a cocaine adulterant will soon reach an end. More information is needed about the diagnosis and treatment of levamisole-induced complications, and the efforts of the medical and public health community is needed to face this challenging problem.
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Affiliation(s)
- Alexandre Larocque
- Emergency Medicine Department, Centre Hospitalier de l'Université de Montréal, Clinical Toxicology Service, McGill University Health Center, Centre Antipoison du Québec, Montreal, Quebec, Canada.
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Agranulocytosis and other consequences due to use of illicit cocaine contaminated with levamisole. Curr Opin Hematol 2012; 19:27-31. [PMID: 22143075 DOI: 10.1097/moh.0b013e32834da9ef] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Most of the illicit cocaine consumed in the United States and elsewhere is contaminated with levamisole, a veterinary medication. Agranulocytosis caused by levamisole exposure through cocaine abuse was first described in 2009. Since then, levamisole has also been shown and is known to cause vascular and neurologic complications. In this review, we provide an overview of the medical consequences of exposure to levamisole from adulterated cocaine. RECENT FINDINGS Within the past year, several new case series have deepened our understanding of the levamisole-agranulocytosis vasculopathy syndrome. The common nature of this exposure has been delineated, cocaine contaminated with levamisole. Significant controversy surrounds the role of granulocyte colony stimulating factor (GCSF) in levamisole-associated agranulocytosis. SUMMARY More than three fourths of cocaine users in the United States are exposed to levamisole; a significant minority of these individuals will develop autoimmune-mediated neutropenia, cutaneous vascular complications, and/or leukoencephalopathy. Levamisole exposure should be considered in the differential diagnosis of patients who present with these conditions in the setting of cocaine abuse. Neutropenia appears to resolve rapidly with cessation of exposure, so that GCSF therapy and a work-up for other causes may not be needed in all patients.
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