A 38–year–old Mexican man presented with one day of sudden onset left shin pain, with generalized weakness and dyspnea. His temperature was 99.0, pulse 90, blood pressure 108/72, respiratory rate 24. On exam he had erythema of the left shin, calf tenderness and decreased range of motion. EKG showed right bundle branch block without ST elevation. Dopplers of the lower extremities were negative. He had a WBC count of 300 with an absolute neutrophil count of 0. Peripheral smear showed no blast forms. Bone marrow showed no evidence of leukemia or lymphoma. CK rose above 8000 and troponin I peaked at 2.3. Urine toxicology was positive for cocaine and cannabinoids. HIV screen was negative. He was medically managed, and placed on broad spectrum antibiotics and filgastrim. Although he initially denied cocaine usage, upon further questioning the patient admitted to having snorted cocaine powder on a daily basis and obtaining the drug from a dealer in Mexico who had been mixing the cocaine with an unknown substance. The etiology of his neutropenia was highly suspected to be levamisole–contaminated cocaine. His WBC count eventually recovered within five days and the skin lesion resolved.
Cocaine can be hazardous not only for its cardiovascular effects but also due to lesser–known toxicities from drug–diluting agents. Our case highlights a patient who ingested cocaine and survived both a coronary event and agranulocytosis, most likely related to the cutting agent levamisole.
Ultimately, the patient survived both common (myocardial infarction) and uncommon (agranulocytosis) complications of cocaine abuse. Levamisole is a veterinary antihelminthic drug once used in humans as adjuvant therapy for colon cancer. Eighty–two percent of seized cocaine in the United States is adulterated with levamisole. Dealers prefer levamisole over traditional cutting agents such as baking soda because it potentiates cocaine’s euphoric effects. However, in select patients (2.3%) it causes agranulocytosis via immune–mediated destruction of cell membranes by antineutrophil antibodies, predisposing patients to serious infections. It may also produce an ANCA–related cutaneous vasculitis. Clinicians need to be cognizant of these rare but life–threatening complications when managing patients who use cocaine.