Fatal levamisole-associated multifocal inflammatory leukoencephalopathy following levamisole-adulterated cocaine use.

Introduction: Levamisole, an antihelmintic, has increasingly been used as a cocaine adulterant. We report a fatal case of levamisole-associated multifocal inflammatory leukoencephalopathy in a 49-year-old female with a history of cocaine use and present findings from magnetic resonance imaging, brain biopsies and hair analysis.

Case summary: The patient was admitted in a comatose state following intentional drug use. Hair analysis revealed significant exposure to both levamisole and cocaine. Despite supportive care and methylprednisolone therapy, the patient's neurological condition deteriorated, leading to death.

Images: Magnetic resonance imaging revealed extensive supratentorial leukoencephalopathy with periventricular and subcortical damage. Brain biopsy confirmed macrophage infiltration and demyelination, consistent with acute disseminated encephalomyelitis-like histopathological features, and provided further insight into the pathological mechanism.

Conclusion: Levamisole-associated multifocal inflammatory leukoencephalopathy can result in irreversible neurological damage and should be considered in patients with a history of cocaine use presenting with coma or neurological symptoms.