Levamisole-Adulterated Cocaine Toxicity: Would You Recognize It?


Pulmonary, abdominal, musculoskeletal, and neurologic examinations were unremarkable. The cutaneous assessment revealed a tender violaceous nonblanching macular eruption with erythematous borders on her arms, legs, and torso. During the mental status examination, the patient was tearful and anxious and expressed worry about her skin lesions.

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With a view to cardiac function, levamisole can cause right heart failure . Furthermore, effects on heart rate have been observed including severe bradycardia, tachycardia and ventricular fibrillation, as well as cardiac dysrhythmias . In veterinary medicine, levamisole is used as an anthelmintic for artiodactyls. It is metabolized to aminorex which has amphetamine-like effects .

To obtain the best experience, we recommend you use a more up to date browser . In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript. DermNet does not provide an online consultation service. If you have any concerns with your skin or its treatment, see a dermatologist for advice.

Levamisole-Adulterated Cocaine Nephrotoxicity:  Ultrastructural Features

No obvious aggravation of certain effects and no emergence of new effects were observed. With the present study, we wanted to address this question. We worked with an animal model, the isolated perfused Langendorff heart, in order to find out if levamisole might cause cardiac adverse effects that may play a role in sudden death after the consumption of street cocaine.

Afterwards CF dropped slowly until the 30th minute and then sharply by 1.14 mL/min to 2.94 mL/min in total. Only for the heart exposed to 0.9-μg levamisole, a final increase was noticed. The heart rate of control hearts (Fig.1a) showed a decrease of 21 to 47 bpm during the exposure to buffer or ACN and restabilized until minute 5 around the individual baseline value.

Changes of CF during the exposure to the evaluated substances and the following recovery period are expressed as the deviation from these individual “base lines” and are presented in Figs. In forensic routine work, cases of death related to the consumption of cocaine occur regularly. However, in some of these cases, the measured cocaine concentrations are quite low and cannot explain death without further ado.

After the application of the substances, we aimed on monitoring the hearts for another 2 h and capture all parameters after 1, 5, 10, 20, 30, 60, 90, and 120 min (“recovery-period”). However, due to a sharp decline of their function some hearts had to be removed earlier. Levamisole is an antihelminthic agent that was originally approved as an immunomodulator in the treatment of autoimmune disorders such as rheumatoid arthritis and nephrotic syndrome and also as a chemotherapy adjunct.

Depending on the level of cocaine abuse or the use of other addictive drugs, psychiatry may need to be consulted during withdrawal. Multiple autoimmune serological markers can be positive including anti-dsDNA, ANCAs, platelet factor IV antibody, lupus anticoagulant, Russell viper venom time, elevated PTT, and anticardiolipin IgM. Careful consultation with rheumatology to consider autoimmune diseases is recommended. Since neutropenia is a common presenting sign of this toxicity, bacterial or fungal infections may be presenting features of levamisole toxicity. Don LeGatt, a clinical toxicologist at the University of Alberta who has studied levamisole in cocaine, told the AP that the drug elevates opiate levels in the brain, much like morphine and codeine. “Once you get those elevated, people tend to feel fairly comfortable and not too bad,” he said.

For some amounts of levamisole and especially cocaine multiple measurements were performed . Figures show mean values of the results for each cocaine/levamisole quantity for a clearer depiction, since obvious deviations of the measured values can i drink alcohol during pregnancy were found only in single cases which are described separately. Figures are presented as stacked line charts in order to make them clearer. This has to be kept in mind when comparing the graphs with the values presented in the text.

  • The British government says around 80 percent of seized cocaine shipments in 2014 contained levamisole.
  • Chronic consumption also causes changes in structure and function of heart and blood vessels like arterial stiffness and increase of left ventricular mass .
  • No obvious aggravation of certain effects and no emergence of new effects were observed.

There were areas of retiform, stellate purpura progressing to bullae on the upper arms and lower legs. Additionally, there was a pink to erythematous maculopapular eruption on the entire back. On the left outer arm, there was a healing, sutured punch-biopsy wound . A cutting agent is used to increase headaches from alcohol withdrawal the weight or volume of a drug product, modify it, or increase its potency. One theory is that levamisole powder looks similar to cocaine, making it cheaper for dealers and manufacturers to produce more products and also making it easier for them to gain more profit with less product.

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Progression of the purpura to necrosis and crusting eschars is common before resolution. Concomitant symptoms of arthralgias, fever, and mouth pain have been reported. Edwards G., Breckenridge what is a high functioning alcoholic A.M. Clinical pharmacokinetics of anthelmintic drugs. Hogan N.A., Hill H.R. Enhancement of neutrophil chemotaxis and alteration of levels of cellular cyclic nucleotides by levamisole.

While exposed to levamisole (Fig. 2b) most hearts presented a deceleration of the heart rate by 7 to 27 bpm. Single hearts showed only little changes (1 μg levamisole) or an acceleration of the heart rate by 10 bpm (1.5 μg levamisole). In the recovery period, the observed alterations were very inhomogeneous. Accelerations as well as decelerations were observed at different points of time, a uniform tendency could not be determined. All substances were administered by a perfusor with a rate of 60 mL/h over 5 minutes (“exposure-period”). During the application of the substances, LVP and heart rate were measured every minute, CF in the first and in the fifth minute.

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Cocaine use and its related complications are well-known public health issues. Recent recognition of levamisole-induced agranulocytosis, vasculitis, and other complications, from contaminated cocaine, dictate that physicians be aware of these potential problems. Levamisole is also believed to enhance users’ dopaminergic responses to cocaine while it is also metabolized into an amphetamine-like chemical, boosting the drug’s overall side effects. While the side effects of levamisole can be horrifying, it’s not the only drug used as a cocaine-cutting agent. Other substances are used as cutting agents in cocaine, including fentanyl and even common household chemicals.

Levamisole is a veterinary pharmaceutical used primarily to treat worm infestations in livestock. Levamisole, the levo enantiomer of tetramisole, was originally developed as an antihelminthic agent. Levamisole is approved by the United States Food and Drug Administration as adjuvant chemotherapy, with 5-fluorouricil, for the treatment of colon cancer. Because it has immunostimulant and immunomodulatory properties, levamisole has also been used for treatment of various autoimmune disorders and cancers .

levamisole coke symptoms

Despite the hype, the chances of cocaine giving you a blood disorder or rotting your skin are incredibly remote. Unless, that is, you're from northern Finland (which I'll get to later). Corrupted cocaine sold in Britain is making people's skin rot. Or so we were told last week, when a series of reports warned of the “flesh eating” cocaine causing people to suffer from a rare blood disorder that makes their flesh decompose and their ears go black. The stories came with images from a gruesome case study in the British Medical Journal, of a woman covered in dark blotches and open sores, looking like something out of a medieval physician's casebook.

Levamisole induced necrosis syndrome

The natural progression of this condition is generally benign, as most symptoms will resolve without intervention. Complete cessation of cocaine use is absolutely necessary because symptoms can recur on rechallenge . Systemic infection in those with agranulocytosis may require hospitalization.

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.

In our experiment, levamisole triggered an increase of LVPmax during the exposure period in some cases which might be caused by a block of open acetylcholine receptors resulting in a calcium influx . This mechanism might also be responsible for an increase of blood pressure and cases of pulmonary hypertension that had been observed under the treatment of patients with levamisole. In our experiments, there was a slight increase of coronary flow and a deceleration of heart rate while hearts were exposed to levamisole. In the recovery period, the heart rate accelerated, seemingly dose dependent, for at least 5 minutes (0.5 μg levamisole) up to 120 min (5 μg levamisole). The interpretation of this effect is challenging as it suggests that levamisole remains in the myocardium even after it has been administered or triggers a reaction in the cells/in the tissue leading to a long lasting effect .

Depending on where you live, between 40 to 90 percent of cocaine contains the drug. The British government says around 80 percent of seized cocaine shipments in 2014 contained levamisole. In Spain, a 2012 study found the drug in 57 percent of cocaine, and in Denmark in the same year it was in 90 percent of samples. In Holland, the figure is 60 percent, and in the US the DEA puts it at 73 percent. Limitations of our study are the rather small number of examined hearts, due to ethical considerations, and the uncertainty regarding the metabolism and the effects of levamisole/aminorex.