Memo: Agranulocytosis in Cocaine Users

To: Emergency Departments
From: Dr. Vera Etches, Associate Medical Officer of Health
Date: April 9, 2009
Subject: Agranulocytosis in Cocaine Users

This memo is to advise you that Ottawa Public Health (OPH) has recently been made aware of a case of agranulocytosis in a person from the Ottawa region whose toxicology tests were positive for cocaine and levamisole.

As shared in the last edition of the Physician’s Update from OPH, cases of agranulocytosis that appear to be related to cocaine contaminated with levamisole have been reported in British Columbia and Alberta. Levamisole is an antibiotic used to treat worm infestation in animals. At least ten people on Vancouver Island and the lower BC mainland have been affected and there have been 39 cases in Alberta in the past several months. Most cases presented with febrile neutropenia and one death was associated with confirmed use of levamisole adulterated cocaine, according to Alberta Health Services (March 2009).

When to suspect agranulocytosis:

Agranulocytosis should be suspected in any cocaine user or suspected cocaine user that presents with symptoms of infection including fever. Also, any skin, abscess or lung infection that appears to be developing more rapidly than usual may indicate acute immunodeficiency.

Recommended testing and follow-up

Initial testing should include

• Complete blood count and differential to assess for neutropenia
• Urine toxicology (for cocaine and levamisole)

Follow-up:

If the neutrophil count is less than 1 and the patient is febrile or has an active infection, an urgent referral should be made to an on-call haematologist for immediate admission to hospital and initiation of broad-spectrum intravenous antibiotics.

Ottawa Public Health is in contact with the Ottawa Police Service, Health Canada and the Ministry of Health and Long-Term Care in order to further assess the risk to the local population. Any suspect cases of agranulocytosis in cocaine users should be reported to Ottawa Public Health, at 613-580-6744, ext. 23675, as we are monitoring the situation closely. For after hour emergencies, please call 3-1-1 and ask for the Public Health Officer on call.

Sincerely,

Vera Etches, MD, CCFP, MHSc, FRCPC

Associate Medical Officer of Health