Adverse effects of levamisole in cocaine users: a review and risk assessment.
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TitleAdverse effects of levamisole in cocaine users: a review and risk assessment.
Published inArch Toxicol 2017; 91(6):2303-13
PubliekssamenvattingThe immunomodulatory adjuvant and antihelminth levamisole is increasingly used as an adulterant in cocaine worldwide. An accumulating body of clinical and toxicological literature has appeared since 2010 describing neutropenia, agranulocytosis, leukoencephalopathy and vasculitis in cases associated with levamisole-adulterated cocaine. Mostly, neutropenia and agranulocytosis were reported, characterized by a decimation of neutrophils. A large proportion of cases also involved vasculopathy, characterized by pronounced black and purple skin purpura with cutaneous necrosis. Females are more susceptible for both agranulocytosis and vasculitis. Another complication reported with levamisole-adulterated cocaine is leukoencephalopathy, a disabling and potentially fatal neurological disorder caused by cerebral demyelination. In this review, all adverse effects associated with therapeutic levamisole and levamisole-adulterated cocaine are described. In addition, this review provides an update of the pharmacology of levamisole, its metabolism, including toxic metabolites and metabolites that are relevant for levamisole's addition to cocaine. Special emphasis is put on the immunopathology and the dose-effect relationship of chronic levamisole exposure. Finally, a risk assessment is provided based on the current level of levamisole adulteration in street cocaine, the dose range calculated per gram and the pattern of chronic exposure in heavy or dependent users.
- Levamisole in cocaine: unexpected news from an old acquaintance.
- Authors: Larocque A, Hoffman RS
- Issue date: 2012 Apr
- Levamisole: a dangerous new cocaine adulterant.
- Authors: Chang A, Osterloh J, Thomas J
- Issue date: 2010 Sep
- Necrotizing peripheral vasculitis/vasculopathy following the use of cocaine laced with levamisole.
- Authors: Farmer RW, Malhotra PS, Mays MP, Egger ME, Smith JW, Jortani SA, Spiller H, Bosse GM, Callen JP, Franklin GA
- Issue date: 2012 Jan-Feb
- Characteristic purpura of the ears, vasculitis, and neutropenia--a potential public health epidemic associated with levamisole-adulterated cocaine.
- Authors: Chung C, Tumeh PC, Birnbaum R, Tan BH, Sharp L, McCoy E, Mercurio MG, Craft N
- Issue date: 2011 Oct
- Levamisole-induced occlusive necrotising vasculitis in cocaine abusers: an unusual cause of skin necrosis and neutropenia.
- Authors: Belfonte CD, Shanmugam VK, Kieffer N, Coker S, Boucree S, Kerr G
- Issue date: 2013 Oct