Cocaine-Levamisole Thrombovasculopathy: A Report From the Southern Network On Adverse Reactions (SONAR) Project
Bibliographic record
Abstract
Abstract Abstract 3403 Introduction: In 2008, five emergency department patients with unexplained neutropenia and thrombovasculitis were reported from Vancouver, Canada. Similar reports have appeared from San Francisco, Denver, Providence, Chicago, New York, and Los Angeles. Methods: 156 case reports of patients of unexplained thrombovasculopathy were identified from the published literature or by SONAR. Results: The average patient age was 44 years old (SD, 11 years); 65% were female. The earliest time to symptom onset was 12 hours following last cocaine use. Dermatologic findings included retiform purpura, purpuric rash, hemorrhagic bullae, or skin necrosis (59% of cases), and lesions on the ears (35% of cases), upper extremities (33% of cases), torso (22% of cases), and the nose (10% of cases). Of 79 patients with available data, 72% presented with severe neutropenia (<1500cells/μl). Among 80 persons who had serologic studies, 95% demonstrated anti-neutrophil cytoplasmic antibodies, 31% were positive for proteinase 3 antibodies, 40% were positive for myeloperoxidase antibodies, 32% were positive for IgM cardiolipin antibodies, and 20% were positive for lupus anti-coagulant. Biopsies (primarily skin) revealed thrombosis in 25%, vasculitis in 6%, and both vasculitis and thrombosis in 20%. Thirty cases tested positive for levamisole. All patients reported recent cocaine use. Treatment of 63 neutropenic patients included supportive care (6 patients; one death; 83% recovery; and 50% spontaneous relapse); G-CSF (15 patients; 100% response; 40% relapse), antibiotics (25 patients; 100% recovery; 28% relapse rate), and corticosteroids (14 patients; 100% recovery; 28% relapse rate). Among 30 persons with skin biopsies identifying thrombosis, treatments included conservative management (5 patients; 100% response rate; 33% relapse) and corticosteroids (13 patients; 100% recovery; 22% relapse rate); among 9 persons with vasculitis, treatments included conservative treatment (2 patients, both recovered no relapses) and corticosteroids (4 patients; 100% response; and 50% relapse). Among 27 persons with thrombosis and vasculitis, treatments included conservative treatment (6 patients; 100% recovery; 50% relapse) and corticosteroids (10 patients; 100% response rates; 40% relapse rate). Severe skin necrosis treatment included skin allografts (6%), above the knee amputation (1 case) and a nose amputation (1 case). One patient with agranulocytosis died of infectious complications. The DEA reports that since 2008, 93% of intercepted cocaine is contaminated with levamisole, a colorectal cancer and anti-helminthic agent. Conclusion: Cocaine-levamisole thrombovasculopathy is a new and increasingly seen syndrome seen among emergency department patients in major cities. A high index of suspicion is essential, as cocaine use may not be obvious and expensive testing and therapies initiated. Appropriate treatment would include withdrawal of cocaine, evaluation of urine samples for levamisole, and conservative management. Disclosures: Gilbert: Allergan: Consultancy; Merz Aesthetics: Consultancy; Johnson & Johnson: Consultancy.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.001 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.001 | 0.000 |
| Scholarly communication | 0.001 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.003 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".