title: Acute coronary syndrome after levamisole-adultered cocaine abuse.
abstract: Cocaine is a well known trigger of acute coronary syndromes. Over the last 10 years levamisole, a veterinary anthelminthic drug has been increasingly used as an adulterant of cocaine. Levamisole was used to treat pediatric nephritic syndrome and rheumatoid arthritis before being withdrawn from the market due to its significant toxicity, i.e. hematological complications and vasculitis. The major complications of levamisole-adultered cocaine reported up to now are hematological and dermatological. The case reported here is of a 25 year old man with a history of cocaine abuse who died at home after complaining of retrosternal pain. Postmortem CT-angiography, autopsy, and chemical and toxicological analyses were performed. An eroded coronary artery plaque was found at the proximal segment of the left anterior descending coronary artery. Two myocardial infarct scars were present in the left ventricle. Microscopic examination of the coronary artery revealed infiltration of eosinophils into the adventitia and intima. Toxicological examination confirmed the presence of cocaine and its metabolites in the peripheral blood, and of levamisole in the urine and pericardial fluid. Eosinophilic inflammatory coronary artery pathologies have been clinically linked to coronary dissection, hypersensitivity coronary syndrome and vasospastic allergic angina. The coronary pathology in the presented case could be a complication of levamisole-adultered cocaine use, in which an allergic or immune-mediated mechanism might play a role. The rise in cocaine addiction worldwide and the increase of levamisole adulterated cocaine highlights the importance of updating our knowledge of the effects of adultered cocaine abuse.
authors.affiliation: University Center of Legal Medicine, Lausanne-Geneva, Rue du Bugnon 21, 1011 Lausanne, Switzerland. Electronic address: katarzyna.michaud@chuv.ch.
authors.forename: Katarzyna
authors.initials: K
authors.lastname: Michaud
authors.affiliation: University Center of Legal Medicine, Lausanne-Geneva, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
authors.forename: Silke
authors.initials: S
authors.lastname: Grabherr
authors.affiliation: University Center of Legal Medicine, Lausanne-Geneva, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
authors.forename: Kebede
authors.initials: K
authors.lastname: Shiferaw
authors.affiliation: Department of Diagnostic and Interventional Radiology, University Hospital of Lausanne, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland.
authors.forename: Franceso
authors.initials: F
authors.lastname: Doenz
authors.affiliation: University Center of Legal Medicine, Lausanne-Geneva, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
authors.forename: Marc
authors.initials: M
authors.lastname: Augsburger
authors.affiliation: University Center of Legal Medicine, Lausanne-Geneva, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
authors.forename: Patrice
authors.initials: P
authors.lastname: Mangin
mesh_terms: D054058:Acute Coronary Syndrome / Q000139:chemically induced* / Q000473:pathology; D000328:Adult; D003042:Cocaine / Q000097:blood / Q000737:chemistry; D019970:Cocaine-Related Disorders / Q000150:complications*; D003331:Coronary Vessels / Q000473:pathology; D003645:Death, Sudden / Q000209:etiology*; D018491:Dopamine Agonists / Q000009:adverse effects* / Q000032:analysis; D004340:Drug Contamination; D004804:Eosinophils / Q000473:pathology; D006801:Humans; D007978:Levamisole / Q000009:adverse effects* / Q000032:analysis; D008297:Male; D009206:Myocardium / Q000473:pathology; D009294:Narcotics / Q000097:blood / Q000737:chemistry; D020097:Natriuretic Peptide, Brain / Q000097:blood; D010446:Peptide Fragments / Q000097:blood; D058226:Plaque, Atherosclerotic / Q000473:pathology; D019210:Troponin I / Q000097:blood; D053802:Tryptases / Q000097:blood
chemical_list: D018491:Dopamine Agonists; D009294:Narcotics; D010446:Peptide Fragments; D019210:Troponin I; C109794:pro-brain natriuretic peptide (1-76); D020097:Natriuretic Peptide, Brain; D007978:Levamisole; D053802:Tryptases; D003042:Cocaine
keywords: Cocaine; Coronary artery; Eosinophils; Levamisole; Sudden death