Cocaine-associated hyponatremia: is levamisole the culprit?

September 20, 2012, 3:15 pm


Hyponatremia Associated with Levamisole-Adulterated Cocaine Use in Emergency Department Patients. Friend K et al. Ann Emerg Med 2012 Jul;60:94-96.


According to reports from the U.S. Drug Enforcement Administration, 69% of illegal cocaine shipments seized in the United States are contaminated with the immunomodulator and anthelmintic agent levamisole. Exposure to this drug from cocaine abuse has been associated with agranulocytosis and necrotizing vasculitis.

This case series, from the University of Pennsylvania School of Medicine, describes 3 patients who presented with hyponatremia (initial sodium  113-124 mEq/L) after snorting cocaine. All patient tested positive for levamisole. The authors note that when this drug was used to treat certain forms of cancer, it was associated with hyponatremia. They fail to cite one additional case report in which a patient presented with acute severe hyponatremia after smoking cocaine. Although the authors of that paper attributed the low sodium level to the effects of cocaine, apparently the patient was not tested for levamisole.

Of course, as the authors of this current paper admit, it is not absolutely clear if other factors contributed to the hyponatremia seen in these cases. It is also not clear to me what clinical significance — if any — the sodium level had. Nevertheless, this is an interesting association to be aware of.

Related posts:

Levamisole-adulterated cocaine: an excellent review

Cocaine, levamisole, and the white blood count 

Dramatic pictures: vasculitis caused by levamisole-contaminated cocaine

Scrotal gangrene after smoking crack

Unusual complication of cocaine abuse

Case reports: neutropenia associated with levamisole-adulterated cocaine

Why is the antihelminthic drug levamisole used to adulterate cocaine?

Cocaine adulterated with levamisole implicated in 21 cases of agranulocytosis

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