Cocaine and Levamisole Cerebral Toxicity

A 45-year-old man presented with a 48-hour history of cognitive impairment. On clinical examination, the patient showed severe apathy, temporospatial disorientation, and mild right hemiparesis. Vital parameters were normal, no extraneurological signs identified. He had past medical history. reported cocaine consumption in 10 previous days. Cerebral magnetic resonance imaging (MRI; Fig) multiple hyperintensities on fluid-attenuated inversion recovery–weighted sequence (Fig, A) involving deep periventricular white matter. Ring-type or nodular enhancement was observed for every lesion postcontrast T1-weighted B), along linear suggestive perivascular space enhancement. There infratentorial gray matter lesion. Etiologic assessment tumoral, infectious, immune diseases negative. Finally, urine screen returned positive levamisole. Because brain MRI characteristic findings levamisole toxicity, following exclusion other hypotheses, he treated intravenous methylprednisolone, 1,000 mg daily 5 consecutive During this period, skills began to improve after 2 days hemiparesis 4 leading complete recovery at end treatment. Interestingly, discharge remained unchanged, contrasting good outcome. At 3-month follow-up, neurological symptoms. significant regression lesions C) resolution D). Levamisole is an antihelminthic agent that commercialized 1971 United States. First cerebral toxicity by Hook et al 1992.1 Although removed from use because its side effects, it now used as cutting approximately 80% currently most common adulterant Europe North America.2 The presentation features confusion, ataxia, hemiparesis, aphasia.3 Therefore, could easily mimic stroke examination. Imaging levamisole-induced leukoencephalopathy seems always feature supratentorial lesions, half patients. Lesions exclusively involve are frequently topography. Periventricular ring-type often described patterns our case.3 Assessment toxic should be systematic first research substances blood performed all acute disorders, especially young patients, compatible findings. has short detection window but can also traced patient's hair. Immunotherapy high-dose corticosteroid main treatment, allowing quick improvement. Cotreatment immunoglobulin plasmapheresis effective alternative refractory cases.3 seem resolve more slowly than manifestations may persist several months. However, cocaine-free relapse new during follow-up call diagnosis into question and, example, criteria sclerosis researched. With around 1% adult population using year,4 recognizing levamisole, crack, become quite relevant, lead specific treatment favorable We thank granting permission publish information. Nothing report.