Cocaine and Ear Necrosis

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

Last week Science Daily had a brief article noting the association of contaminated cocaine with ear necrosis:   Contaminated Cocaine Triggers Decaying, Dying Skin  (photo credit) 

I’ve written about skin complications from drug abuse in the past, but this is not one I knew of.  Most common are skin and soft tissue infections (SSTIs).

The crusty, purplish areas of dead skin (purpura) that can occur with this contaminated cocaine are extremely painful and can open the door to nasty infections.  (note the lower lobe of the ear in the photo)

Apparently the cocaine is contaminated with a de-worming drug commonly used by veterinarians called levamisole,  noted by the U.S. DEA to have been found in 30% of confiscated cocaine in 2008 and 70% in 2009.

This complication from the use of the contaminated cocaine was recently reported in the June issue of the Journal of the American Academy of Dermatology (full reference below).  The report highlights six new and very similar patient cases of purpura, mostly on and around the ears, following the contaminated cocaine use.  There were six cases --  four seen in Rochester, N.Y. and two in Los Angeles. 

Although in each case an extensive battery of blood tests ruled out the usual causes of purpura, the JAAD paper authors write “because testing is not easily performed, we did not test for levamisole in the serum or blood to prove this is the causative agent.”

From the Science Digest article:

According to Mary Gail Mercurio, M.D., an author and associate professor in the Department of Dermatology at the University of Rochester Medical Center, "When we first started seeing these patients they all had a similar clinical picture, but they were really an enigma because they weren't falling into any other pattern we'd seen before. When a colleague at the National Institutes of Health mentioned levamisole contamination, we did toxicity screens and lo-and-behold, all the patients came up positive for cocaine. We had our diagnosis."

Drug enforcement officials have detected levamisole -- which was once used to treat colon cancer -- in cocaine since 2003, but have watched it increase rapidly in recent years. The Drug Enforcement Administration says that the drug, which is inexpensive, is used more and more as a diluting agent in order to stretch supplies. Study authors report that levamisole is known to increase dopamine, a neurotransmitter that helps control the brain's reward and pleasure centers, causing experts to believe it is also added to cocaine to further enhance or prolong the user's high.

Researchers don't know how levamisole causes purpura, which occurs when vessels become plugged and blood can't flow to the skin, leading to skin death and the resulting purplish, crusty appearance. Cocaine alone constricts blood vessels, which is probably the first step, but how levamisole contributes is not yet understood, Mercurio said.

The purpura can occur with both smoking and snorting of the tainted cocaine.  Treatment options include steroids to prevent inflammation, but stopping the exposure to cocaine is the best medicine.

REFERENCES

Characteristic purpura of the ears, vasculitis, and neutropenia–a potential public health epidemic associated with levamisole-adulterated cocaine; Catherine Chung, Paul C. Tumeh, Ron Birnbaum, Belinda H. Tan, Linda Sharp, Erin McCoy, Mary Gail Mercurio, Noah Craft; Journal of the American Academy of Dermatology, 09 June 2011, (10.1016/j.jaad.2010.08.024)

U.S. DEA:  Drugs of Abuse – 2011 Edition