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Paper text:
a 22-year - old female with a history of food intake from outside was diagnosed to have salmonellosis with agranulocytosis .
however , 2 months after discharge , she again presented with agranulocytosis ; this time with tonsillitis . this time the family revealed that she had been taking levamisole .
 we report this case because levamisole - induced agranulocytosis is extremely rare and also because of the co - existing and confounding factor of salmonellosis .
her initial evaluation revealed the presence of marked agranulocytosis ( total leukocyte count : 460/cumm ; differential leukocyte count :
the rest of the counts were normal ( hemoglobin [ hb ] : 12.6 g / dl , platelets : 204,000/cumm ) .
exact species could not be ascertained as the isolate was nonreacting to the available antisera , including typhi and para typhi .
simultaneously , granulocyte - colony stimulating factor ( g - csf ) was also started .
there was a steady improvement in her counts , which was normalized by the 5 day of initiating g - csf and the patient was soon discharged thereafter . among her other investigations ,
peripheral smear was reported as  marked leukopenia and neutropenia ,  other cell lines being normal .
bone marrow study was also done prior to the administration of g - csf , which came as 
 subsequent peripheral smear study after the normalization of white blood cell count was normal .
other investigations , including b12 assay , serum uric acid , lactate dehydrogenase levels , hiv , hepatitis b surface antigen , hepatitis c virus , and rheumatoid arthritis ( ra ) factor , were essentially normal . only anti - nuclear antibody ( ana ) was reported as positive . however ,
the patient was followed up as an outpatient for one more month without any incident .
again , she was found to have marked agranulocytosis ( total leukocyte count : 800/cumm ; differential leukocyte count :
n 1% , l 22% , e 1% , m 1% - out of 25 cells ) .
the rest of the counts were normal ( hb : 14 g / dl , platelets : 220,000/cumm ) .
peripheral smear and bone marrow study was again repeated ; the results were also the same .
cultures including throat swab cultures were also negative . again , the intake of any drugs from outside was denied .
antifungals were added empirically as before . clinical response and counts mirrored the earlier admission ; by the 5 day of initiating g - csf , her counts normalized .
six days into the treatment , the patient 's father brought a tablet strip which was prescribed to her by a local gp for some  illness  causing hair fall ; the details of which were unclear .
she had taken one tablet ( 50 mg ) 15 days prior to her first admission and again 15 days prior to her second admission .
this information was not revealed by the family since they considered the drug to be  insignificant . 
the patient was followed up as an outpatient for another 3 months and continued to be normal .
this synthetic imidazothiazole derivative has also been used for its immunomodulatory properties : it has been used for the treatment of ra as a disease - modifying anti - rheumatic agent and with 5-fluorouracil for the treatment of dukes stage c colon cancer .
it has also been used as a steroid - sparing agent in childhood steroid - dependent nephrotic syndrome .
however , later it was withdrawn from some countries because of the reports of agranulocytosis .
currently , it is primarily used as an anti - helminthic medication in veterinary medicine .
the illegal use of levamisole , however , continues , as an adulterant with cocaine .
illicit users of cocaine are unaware of this deadly cocktail and end up with levamisole toxicity .
drug- induced agranulocytosis has also been described in salmonella infection . however , a case of salmonella infection where levamisole was an unsuspecting cause of agranulocytosis has not been described .
causality assessment with naranjo adverse drug reaction probability scale , suggests that agranulocytosis was probably related to the use of this drug ( score 7 ) .
recurrent agranulocytosis due to repeated exposure to levamisole has also not been described in the literature . though salmonella infection is a recognized cause of agranulocytosis , any patient presenting with repeated agranulocytosis after an initial recovery should raise the suspicion of an alternative cause , especially drug - induced .
in our country where rules regarding prescription drugs are rather lax and this combined with poor knowledge and lack of awareness on the part of the consumer about the medicines they take ; the timely and right diagnosis of the cause of an adverse event and its management will remain a challenge for the prescriber .
agranulocytosis is a rare complication of levamisole . 
 we report a 22-year - old female who developed agranulocytosis due to levamisole . 
 the patient initially presented with salmonellosis and agranulocytosis , and then she recovered with treatment . 
 however , 2 months after discharge , she again presented with tonsillitis and agranulocytosis . 
 this time the family revealed that she had been taking levamisole . though salmonella infection is a recognized cause of agranulocytosis , any patient presenting with repeated agranulocytosis after an initial recovery should make the clinician suspect another cause , especially drug - induced . 
 a case of salmonella infection where levamisole was an unsuspecting cause of agranulocytosis has not been described in indexed literature . 
 recurrent agranulocytosis due to repeated exposure to levamisole has also not been described .