Why is agranulocytosis occurring in cocaine users?
The New Mexico Department of Health (NMDOH) has issued a health alert regarding a cluster of patients who presented with agranulocytosis over the past 15 months and had cocaine use in common. Most of the cases are in New Mexico, but there also have been cases in Arizona and in Colorado. NMDOH believes that levamisole, an antimetabolic drug used in veterinary practice as a de-worming agent, may have contaminated the cocaine. Levamisole has been detected in cocaine samples in New Mexico and in a post-mortem blood sample of one of New Mexico's cocaine-using agranulocytosis cases. Death may occur secondary to infection in immunocompromised patients. Previous cases have been noted in Canada and California. There is no evidence that the type of cocaine (e.g. powder or crack) or route of use affects the risk for agranulocytosis.
Consider agranulocytosis in cocaine users with recent signs and/or symptoms of infection.
a) Perform a CBC w/ manual differential in potential cases. Peripheral blood smears have shown a marked decrease or absence of neutrophils.
b) Obtain microbiologic cultures of blood, wounds and body fluids in febrile patients.
If you see a patient with cocaine use and agranulocytosis, please call the TN Poison Center and ask to speak to the Toxicologist-on-call.
Question prepared by: Donna L. Seger, M.D. Medical Toxicologist