Acquired Agranulocytosis- A Case Report of Levamisole Induced Agranulocytosis from Cocaine Abuse

Abstract

Agranulocytosis is a rare condition with incidence of 1-5 cases per million. Immunosuppressive agents are one of the most common cause for drug induced agranulocytosis. We are presenting an uncommon presentation of agranulocytosis in a patient with no history of hematologic disorders, that might have been caused by adulteration of cocaine with levamisole with significant history of cocaine abuse. A 40 year old male with history of cocaine abuse presented with history of fevers, sore throat and abdominal pain of 1 day duration. On exam, he is febrile with T: 103 F and has mild diffuse tenderness of abdomen without rebound or guarding. Initial labs revealed absolute neutrophil count (ANC) of 0/mm3 and urine tox screen positive for cocaine. On further imaging he was found to have left maxillary sinusitis and small bowel enteritis on computer tomography of abdomen. Patient was empirically started on vancomycin and cefepime along with supportive care. Findings of agranulocytosis with history of drug abuse prompted us to check for infectious causes with rapid strep test, epstein barr virus, acute hepatitis panel, cytomegalovirus, HIV, parvo B19, flu which came back normal. On day 3, symptoms improved with continued supportive care and improvement in ANC from 0 to 500/mm3 with negative blood cultures and eventual discontinuation of antibiotics. ​In our case, levamisole is thought to be the most likely cause for agranulocytosis ​with significant history of cocaine abuse. ​Cocaine is the most common cause of drug abuse related emergency department visits in united states. ​Levamisole is an immunomodulatory agent and common adulterant of cocaine that can cause agranulocytosis. Although it was found to be associated with as many as 75 % of cocaine users, but the exact mechanism why only some population are affected by significant agranulocytosis is unclear warranting further research.