Clinicopathologic features of agranulocytosis in the setting of levamisole-tainted cocaine.
Levamisole is a known contaminant of cocaine and, via this route, has been associated with otherwise unexplained agranulocytosis. Levamisole is currently present in the majority of cocaine samples seized by the US Drug Enforcement Agency. We identified 20 cases of unexplained agranulocytosis in our practice locations of Albuquerque, NM, and Vancouver, Canada. Epidemiologic investigation revealed recent or ongoing cocaine use in 14 cases (70%). Certain morphologic features, including circulating plasmacytoid lymphocytes, increased bone marrow plasma cells, and mild megakaryocytic hyperplasia, were associated with the cocaine-exposed group. Of 5 patients tested, 3 (60%) were HLA-B27+ and showed antineutrophil antibodies, consistent with known associations of levamisole-induced agranulocytosis. One patient, who was positive for cocaine and levamisole by toxicology testing, died of infectious complications. Inadvertent consumption of levamisole via cocaine is a severely under-appreciated risk factor for agranulocytosis, and specific laboratory features are suggestive of this etiology.
Czuchlewski
David R
DR
Department of Pathology, Division of Hematology/Oncology, University of New Mexico Health Sciences Center, Albuquerque, NM 87102, USA.
Brackney
Monica
M
Ewers
Christina
C
Manna
Jonaki
J
Fekrazad
M Houman
MH
Martinez
Afton
A
Nolte
Kurt B
KB
Hjelle
Brian
B
Rabinowitz
Ian
I
Curtis
Brian R
BR
McFarland
Janice G
JG
Baumbach
Joan
J
Foucar
Kathryn
K
D000328:Adult; D000368:Aged; D000380:Agranulocytosis / Q000139:chemically induced / Q000276:immunology* / Q000473:pathology*; D001323:Autoantibodies / Q000276:immunology; D003042:Cocaine / Q000506:poisoning*; D004340:Drug Contamination; D005260:Female; D006801:Humans; D006965:Hyperplasia / Q000276:immunology / Q000473:pathology; D007978:Levamisole / Q000506:poisoning*; D008297:Male; D013058:Mass Spectrometry; D008875:Middle Aged; D009504:Neutrophils / Q000276:immunology / Q000473:pathology; D010950:Plasma Cells / Q000276:immunology / Q000473:pathology
D001323:Autoantibodies; D007978:Levamisole; D003042:Cocaine