A Case of Levamisole-Induced Agranulocytosis

Received Sep 18, 2017; Accepted Jan 2, 2018

This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

1. Introduction

Levamisole is an immunomodulator that is found in almost seventy to eighty percent of cocaine shipments according to the Drug Enforcement Agency (DEA) [1, 2]. There were approximately 1.5 million American cocaine users each month in the year of 2013 making levamisole a relevant public health concern [3]. We present a case of levamisole-cocaine-induced agranulocytosis with the aim to raise awareness regarding the possible complications of this compound.

2. Case Report

A sixty-eight-year-old male presented to the Emergency Department (ED) complaining of recurrent diarrhea and a documented fever of 312 K for one-day duration. The patient had a past medical history of end-stage renal disease on hemodialysis, insulin-dependent type II diabetes mellitus, essential hypertension, and chronic cocaine dependence. On further history, the patient reported the use of cocaine over the past five years with an average use of three times a week but could not specify a certain amount on each time. The patient disclosed that he had used cocaine earlier that day.

At admission, blood pressure was 106/78, heart rate was 96 beats per minute, respiratory rate was 18, temperature was 312.2 K, and oxygen saturation was 93% on room air. Physical examination showed a thin, malnourished male with right below knee amputation who was in mild distress. No cutaneous manifestations were noticed, and no other abnormalities were appreciated on the rest of the patient’s physical examination. Laboratory workup was done and included a complete blood count (CBC) with differential, which showed a WBC count of 1.9 × 10⁹/L (reference range: 4.0–11.0 × 10⁹/L), segmented neutrophils 4% (reference range: 40–70%), bands 1% (reference range: 0–6%), immature granulocytes of 0.0% (reference range: 0.0–0.9%), and lymphocytes 70% (reference range: 16–45%). Basophils, eosinophils, and monocytes were within normal limits. Hemoglobin was 9.8 g/dL (reference range: 12.5–17 g/dL), which was around baseline and was attributed to the patient’s end-stage renal disease, and platelet count was 237 × 10⁹/L (reference range: 150–450 × 10⁹/L). A complete metabolic profile was also obtained showing a serum potassium of 3.1 mmol/L (reference range: 3.6–5.0 mmol/L), creatinine of 371.4