Levamisole-Adulterated Cocaine: A Case of Vasculitis and Severe Neutropenia

Levamisole is an immunomodulatory agent that was formerly used in the United States as a disease-modifying antirheumatic drug (DMARD) for rheumatoid arthritis (RA). More recently, it has become a common adulterant in cocaine. Levamisole exposure has been associated with a broad spectrum of adverse effects, such as neutropenia, agranulocytosis, distinctive skin lesions, vasculitis, arthralgias, and leukoencephalopathy. While the literature on complications related to levamisole exposure is currently sparse, given its increasingly common use as a cutting agent in cocaine, it is likely that they are underreported. Because of this, heightened vigilance among clinicians is warranted. Here we present an unusual case of levamisole toxicity causing both vasculitis with systemic and cutaneous pathology, including severe neutropenia complicated by septic shock.