Levamisole tainted cocaine causing severe neutropenia in Alberta and British Columbia
1 Edmonton Zone Medical Office of Health, Alberta Health Services, Suite 101 West Tower, 14310-111 Avenue, Edmonton, AB (T5M3Z7), Canada
2 Epidemiology Services, British Columbia Centre for Disease Control 655 West 12th Ave, Vancouver British Columbia (V5Z 4R4), Canada
3 School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue, Vancouver British Columbia, (V6T 1Z3), Canada
4 Department of Medicine (Community Medicine), University of Alberta, Suite 4000 RTF, 8308 - 114 Street, Edmonton, Alberta (T6G 2V2), Canada
5 Department of Laboratory Medicine & Pathology, 4B4.08 Mackenzie Health Sciences Centre, University of Alberta Hospitals, Edmonton, Alberta (T6G 2R7), Canada
6 Department of Medicine (Hematology & Clinical Oncology), University of Alberta, 2E3 Walter Mackenzie Centre, Edmonton, Alberta (T6G 2B7), Canada
7 Department of Public Health Sciences, University of Alberta, 3-50 University Terrace, 8303 - 112 Street, Edmonton, Alberta (T6G 2T4), Canada
Harm Reduction Journal 2009, 6:30 doi:10.1186/1477-7517-6-30Published: 17 November 2009
Five cases of severe neutropenia (neutrophil counts < 0.5 per 109 cells/L) associated with exposure to cocaine and levamisole, an antihelimithic agent no longer available in Canada, were identified in Alberta in 2008. Alberta and British Columbia (BC) public health officials issued an advisory and urged health care professionals to report cases to public health. This paper presents the findings of the public health investigations.
Cases were identified prospectively through reporting by clinicians and a retrospective review of laboratory and medical examiners data from January 1, 2006 to March 31, 2009. Cases were categorized as confirmed, probable or suspect. Only the confirmed and probable cases are included in this paper.
We compare cases of severe neutropenia associated with tainted cocaine (NATC) identified in Alberta and BC between January 1, 2008 to March 31, 2009. Of the 42 NATC cases: 23(55%) were from Alberta; 19(45%) were from British Columbia; 57% of these cases reported crack cocaine use (93% of those who identified type of cocaine used); 7% reported using cocaine powder; and the main route of cocaine administration was from smoking (72%). Fifty percent of the NATC cases had multiple episodes of neutropenia associated with cocaine use. Cases typically presented with bacterial/fungal infections and fever. One Alberta NATC case produced anti-neutrophil antibodies, and four were positive for anti-neutrophil cytoplasmic antibody (ANCA). Analysis of two crack pipes and one drug sample obtained from NATC cases confirmed the presence of both cocaine and levamisole. A further 18 cases were identified through the retrospective review of laboratory and medical examiner data in Alberta
Our findings support a link between neutropenia and levamisole tainted cocaine; particularly from smoking the crack form of cocaine. Some patients may be genetically predisposed to develop levamisole-related neutropenia. Awareness of the differential diagnosis will assist clinicians with case timely detection and appropriate management.