A 44-year-old woman with cutaneous bullae and extensive skin necrosis

Lupus anticoagulant and ANCA associated thrombotic vasculopathy due to cocaine contaminated with levamisole: a case report and review of the literature

A 2010 US report recently detected the presence of levamisole in greater than 77 % of seized cocaine samples. A syndrome of retiform purpura, often involving ears and flanks, with vasculopathy or vasculitis on biopsy, associated with anti-nuclear cytoplasmic antibodies as well as antiphospholipid antibodies, previously associated with therapeutic use of levamisole has now re-emerged, and is associated with cocaine adulterated with levamisole. Patients with this unusual constellation of signs and laboratory findings should be questioned about exposure to cocaine.

Levamisole-induced vasculopathy: a report of 2 cases and a novel histopathologic finding

Although cocaine-induced pseudovasculitis and urticarial vasculitis have been reported in the past, levamisole-induced vasculopathy with ecchymosis and necrosis, termed here LIVEN, has only recently been described in association with cocaine use. Levamisole, a veterinary antihelminthic agent used previously as an immunomodulating agent, is present as a "cutting agent" in approximately two-thirds of the cocaine currently entering the United States. Levamisole is believed to potentiate the effects of cocaine and may also be used as a "signature" for tracing its market distribution. Herein, we report 2 cases of LIVEN in patients with histories of chronic cocaine use. In both the cases, a temporal association with neutropenia preceding the eruption was noted. A novel histopathologic finding present only in the second case was the presence of extensive interstitial and perivascular neovascularization. Our 2 cases reaffirm that neutropenia may precede the cutaneous eruption of LIVEN. Case 2 extends the spectrum of histopathologic findings to include the novel phenomenon of neovascularization-hitherto unreported in this entity.

Vasculopathy, hematological, and immune abnormalities associated with levamisole-contaminated cocaine use

OBJECTIVES

To report 4 cases of cocaine-related purpura and to review previously reported cases of levamisole, levamisole-contaminated cocaine, and cocaine-induced vasculopathy.

METHODS

We describe 4 patients suspected of vasculopathy associated with levamisole-tainted cocaine use. A retrospective review of the literature was performed using the PubMed, PubJet, MD consult, and Cochrane review databases.

RESULTS

Four cases (2 females and 2 males), 46 to 55 years of age, presented with cocaine-related purpura, mainly affecting the ears, neutropenia, and autoantibodies. Skin biopsies revealed a mixed pattern of leukocytoclastic vasculitis and microvascular thrombosis in 2 cases, and pure thrombosis in the third case. The mixed vasculopathic pattern in association with neutropenia, both known adverse effects of levamisole, and levamisole positivity in 2 cases point to this compound as the true etiologic agent in our patients. Eleven cases of levamisole-contaminated cocaine-induced vasculopathy have been described in the English literature. Among these, 10 were females. Age range was 22 to 57 years. Urine levamisole positivity was tested and confirmed in 3 of the 11 cases. The clinical characteristics, laboratory features, histology, treatment, and recovery rates were compared for the published cases of levamisole, levamisole-contaminated cocaine, and cocaine-induced vasculopathy.

CONCLUSIONS

Adulterated cocaine abuse is an increasingly recognized phenomenon in North America. Levamisole is among the many contaminants that have been detected in seized cocaine throughout North America and Europe. Recent reports described an association between levamisole-tainted cocaine and purpuric skin rash, neutropenia, and the presence of autoantibodies.