Agranulocytosis in Cocaine Users

People with agranulocytosis related to powder cocaine use in BC and Alberta are being reported. At least seven sporadic cases in BC have been diagnosed in the past year, most notably on Vancouver Island with now 3 cases throughout Fraser Health in the last week. Five cases have been reported in Alberta since July.

The agranulocytosis is suspected of being due to an adulterant called levamisole (a hog deworming medication and former anti-cancer medication). Levamisole is a known cause of agranulocytosis in susceptible individuals and has been identified in cocaine obtained in Alberta, USA and Europe. Information about cocaine contamination in BC is pending. This contamination is suspected of occurring at or near the source of cocaine production. Whether the modes of powder cocaine use (smoking, snorting, or injecting) affects the risk remains to be determined.

Case presentation is often with febrile, acute and profound neutropenia, and may involve sepsis. The total white blood cell count may only be slightly below normal as the lymphocytes and other white blood cells are often normal.

Physicians should suspect agranulocytosis in cocaine user with recent onset of fever or chills or infections. This would warrant initial blood work to assess for neutropenia and a spot urine sample for cocaine. BCCDC is working on the availability of urine testing for Levamisole, but this is not currently available in BC. Conversely, if severe neutropenia is found, the physician should inquire about cocaine use as a risk factor. Explaining the issue of contamination to the patient may facilitiate disclosure.

If initial blood work indicates neutropenia then consultation with a haematologist or haematological pathologist should occur to determine if a bone marrow biopsy is warranted. If the neutrophil count is less than 1 and the patient is febrile or has an active infection, an urgent referral is warranted. The patient will require admission to hospital immediately, an infectious work-up including blood cultures, and appropriate empiric broad-spectrum intravenous antibiotics.

Recovery generally occurs after 7-10 days, but close monitoring is required as the risk of mortality from sepsis is high. Recurrence has been noted for some people who return to cocaine use.
Also, hog dewormer can cause serious allergic reactions which can be fatal. If your patient experiences any of the following symptoms shortly after taking any drug, they might be experiencing allergic reaction to levamisole:

• Lips, tongue, and throat tingling and swelling
• Hives – itchy red spots appearing on the body shortly after drug use
• Chest tightness, difficulty breathing
• Rapid heart beating, feeling faint

If clinicians become aware of any more cases, please notify the medical health officer by telephone at 604-587-3828 or 1-877-342-6467 with the patient’s name, date of birth, PHN, address and phone number.

Advice to clients at risk should include a warning that the cocaine being sold is potentially cut with a dangerous substance that could harm their immune systems. They should seek medical attention immediately if they develop a fever over 38°C. Also any skin, abscess or lung infections that appear to be developing more rapidly or are progressing more seriously may indicate an underlying acute immunodeficiency and require even more immediate treatment than usual.

To contact the Medical Health Officer in your community during working hours, please call 604-587-3828 or 1-877-342-6467. After hours, please call the Public Health Emergency Pager at 604-527-4806 and ask for the Medical Health Officer on-call.