1936 Levamisole Contaminated Cocaine Presenting as Gastrointestinal Ulcerations and Bleed

Abstract

INTRODUCTION: Levamisole is a widely used cutting agent for cocaine and it also contributes to increased quantity of cocaine. Gastrointestinal (GI) ulcers and bleed is a rare presentation of levamisole intoxication. We report a case of GI ulcers and bleed suspected to be from levamisole contaminated cocaine. CASE DESCRIPTION/METHODS: A 58 year old female presented with sore throat, headache, oral ulcers and multiple necrotic skin lesions following a tooth extraction. On examination, she was noted to have oral ulcers, peri-anal necrotic ulcers, finger eschars and a left lower extremity open blister. Painful violaceous purpuric patches with well-delineated dusky necrotic centers and a bright erythematous rim were also observed peri-anally. Laboratory studies revealed neutropenia, hyponatremia, acute kidney injury, positive antineutrophilic antibody, Hepatitis C, HSV 1 and 2, D-dimers, antidouble-stranded DNA antibodies, anti-neutrophil cytoplasmic antibodies, lupus anticoagulant antibodies and decreased protein S levels. Urine toxicology screen was positive for cocaine and opiates. Patient admitted to cocaine use due to pain from the extracted tooth. Computed Tomography (CT) of abdomen revealed moderate ascites and body wall edema. She was managed with intravenous fluids, pressors, antibiotics, antiviral, antifungal therapy. She also received treatment with filgastrim. Over the course of her hospital stay, she developed lower GI bleed and required multiple units of blood transfused. Endoscopy revealed a clean based gastric ulcer and multiple cecal colon ulcers which was managed with epinephrine injections. DISCUSSION: Levamisole is mostly absorbed from the GI tract and metabolized by the liver. Our patient presented with immune derangements and GI bleed after the use of cocaine to help with her pain from tooth extraction. Laboratory results were compatible with levamisole contamination. CT of the abdomen showed moderate ascites and anasarca similar to MRI characteristics of levamisole-induced leukoencephalopathy which show peripheral ring-type enhancement and edema around lesions. The mechanism of levamisole in the formation of GI ulcers is presumed to be related to ischemia. To our knowledge, this is the first case of levamisole-contaminated cocaine induced gastrointestinal ulceration and bleed. This case illustrates the potential for severe gastrointestinal ulcers and bleed with the use of levamisole and the value of high index of suspicion.