Agranulocytosis in Cocaine Users

Please continue to watch for and report cases of agranulocytosis in cocaine users.

As of February 18, BC has 14 reported cases of agranulocytosis associated with cocaine use, crack cocaine in eight cases, powder in two, and an unknown type in four. In one case, urine was sent to Alberta and levamisole was confirmed. In another case, a cocaine sample was sent via the police to the Drug Analysis Lab in Burnaby and probable levamisole was detected (the lab is unable to differentiate between racemates levamisole and tetramisole)

More cases are suspected: two in VIHA, one in Northern Health, and 5 in Fraser Health.

Warn cocaine-using patients that the cocaine being sold may be cut with a hog worming medication that can cause dangerous harm to their immune systems. If they develop a fever over 38°C or any unusually severe or rapidly developing skin, abscess or lung infections, they should go to the nearest emergency department immediately.

Consider a CBC and spot urine for cocaine in any cocaine user with recent onset of fever or chills or infections. Conversely, ask about cocaine use in patients with unexplained severe neutropenia.

Consultation with a hematologist or hematological pathologist is recommended for neutropenia associated with cocaine use. If the neutrophil count is under 1 and the patient has a fever or active infection, urgent referral is warranted, with immediate hospital admission, infectious work-up including blood cultures, and appropriate empiric broad-spectrum intravenous antibiotics. Risk of death from sepsis is high. Otherwise, neutropenia generally resolves in 7-10 days. Neutropenia may recur in patients who return to cocaine use.

Levamisole can also cause anaphylaxis, sometimes fatal, presenting with hives and/or tingling/swelling of lips, tongue or throat, and/or chest tightness, difficulty breathing, tachycardia, or feeling faint.

Please report cases of agranulocytosis associated with suspected or known cocaine use by completing and faxing the report form, along with any additional information to:

• BCCDC at 604-660-0197, Epidemiology Division, Attention Dr. Buxton; and
• A Fraser Health Medical Health Officer at one of the fax numbers noted below.

Any information regarding the source of cocaine and anything different that the patient may have noticed about the cocaine, e.g., unique taste or smell, is of particular interest.

BCCDC can arrange levamisole testing of urine specimens taken within 48 hours of cocaine use:

• Send the Provincial lab a minimum 10 cc of urine in a leak-proof plastic screw top container.
• Label the requisition with:
• Patient name, DOB, and PHN number
• Date and time of specimen collection
• Name & address of the ordering MD and other physician(s) to whom results are to be sent
• STAT cocaine screen / agranulocytosis (Attn Dr. Isaac-Renton, ? levamisole toxicity)
• Yin Chang at 604-660-6561 must be advised when the urine sample is sent to the Prov Lab. Specimens are stored at -20C prior to shipping to Alberta, where testing should be done within 3 weeks of collection. BCCDC will send results to the indicated physician(s) and the local MHO.