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Koster MJ, Guarda M, Ghaffar U, Warrington KJ. Rheumatic masqueraders: mimics of primary vasculitis - a case-based review. Expert Rev Clin Immunol 2024; 20:83-95. [PMID: 37837326 DOI: 10.1080/1744666x.2023.2270774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 10/10/2023] [Indexed: 10/16/2023]
Abstract
INTRODUCTION Vasculitis conditions are often serious and sometimes fatal diseases, therefore it is paramount to diagnose correctly and treat appropriately. Mimics of primary vasculitis can include either non-inflammatory syndromes or secondary vasculitis where the underlying etiology of the vasculitis is being driven by infection, malignancy, drug-effect or other. AREAS COVERED This review comprises six individual cases of vasculitis mimics. Each case is presented and the clinical, radiographic, and histological features that distinguish the case from primary vasculitis are highlighted. Key mimics in large, medium and small vessel vasculitis are outlined. EXPERT OPINION The diagnosis of vasculitis requires a comprehensive assessment of clinical, radiographic, and histologic features. Clinicians should be familiar with mimics of primary vasculitis conditions. In the case of non-inflammatory mimics, it is important to differentiate from primary vasculitides in order to avoid unnecessary and potentially harmful immunosuppression. For cases of secondary vasculitis, identification of the correct etiologic cause is critical because treatment of the underlying stimulus is necessary for successful management and outcomes.
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Affiliation(s)
- Matthew J Koster
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - Max Guarda
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - Umar Ghaffar
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - Kenneth J Warrington
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
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2
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Hellwege RS, Sitter T, Wörnle M. [Vasculitis oft the skin after cocaine use]. Dtsch Med Wochenschr 2023; 148:1182-1186. [PMID: 37657456 DOI: 10.1055/a-2142-1530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Abstract
HISTORY AND CLINICAL FINDINGS A 20-years-old patient presented himself to our emergency room with extensive and extremely painful purpura with necrotizing spots and blisters, especially on the lower extremities, but also on the arms, trunk and ears. There was a pre-existing use of cocaine. MEDICAL EXAMINATIONS Laboratory tests showed increased signs of inflammation as well as an increase in proteinase 3- and myeloperoxidase-ANCA (Anti-neutrophil cytoplasmatic antibody). DIAGNOSIS In combination with the medical history, the clinical findings, and the laboratory values, vasculitis of the skin after cocaine use was revealed. THERAPY AND COURSE Under therapy with steroids and cocaine abstinence, there was a regression of the changes. CONCLUSION Vasculitis is a serious complication of cocaine use.
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Affiliation(s)
| | - Thomas Sitter
- Medizinische Klinik und Poliklinik IV, LMU Klinikum Campus Innenstadt, Ludwig-Maximilians-Universität München
| | - Markus Wörnle
- Zentrale Notaufnahme, LMU Klinikum Campus Innenstadt, Ludwig-Maximilians-Universität München, München, GERMANY
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3
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Research on the Removal of Levamisole Residues in Bovine, Ovine, Caprine, Porcine and Poultry Tissues. SEPARATIONS 2022. [DOI: 10.3390/separations9090261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
In this paper, we set the waiting time for the elimination of levamisole residues at a safe level from tissues (muscles and organs) from animals treated with levamisole 10%—oral solution. We studied the depletion of levamisole residues by high performance liquid chromatography with a mass spectrometer (limit of quantification 2 μg/kg) in the tissues of bovine, ovine, caprine, porcine and poultry (chickens and pigeons) after administration of levamisole (10 mg levamisole/kg body weight for cattle, sheep, goats, pigs and 20 mg levamisole/kg body weight for birds). We found that in cattle, sheep and goats at 7 days after treatment, the residues of levamisole in the liver and at 14 days and in the other tissues were below the established limit value. In pigs at 7 days, residues from all tissues were below the set limit value. Residue depletion in chickens treated with levamisole was rapid, such that 3 days after treatment, the residues in all tissues were below the set limit. Residue depletion was slower in turkeys than in chickens.
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Effect of a Single and Triple Dose of Levamisole on Hematological Parameters in Controlled Inflammation Model. Animals (Basel) 2022; 12:ani12162110. [PMID: 36009703 PMCID: PMC9404755 DOI: 10.3390/ani12162110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/10/2022] [Accepted: 08/14/2022] [Indexed: 11/17/2022] Open
Abstract
This study aimed to evaluate the impact of single and triple administration of levamisole on the dynamics of hematological parameters during experimental pleuritis. The experiment was performed on female Buffalo rats. Rats were randomly assigned to two equal groups that received 1 and 3 doses of levamisole every 2, 24 and 48 h, respectively. Following the experiment, blood samples for the measurement of hematological parameters were collected. The study group receiving three doses of levamisole observed a significant reduction of red blood cell count at 48 h post administration and an increase in mean corpuscular volume compared to the control inflammation group. The administration of a single dose of levamisole results in a significant increase in hematocrit at 72 h, an increase in white blood cell count at 24 h and 72 h, and an increase in neutrophil count at 72 h compared to the control inflammation group. Administration of a single and triple dose of levamisole showed statistically significant modification of some hematological parameters and thus modulates the inflammatory process. In the lungs, this results in a reduction in leukocyte infiltrations around the bronchi and blood vessels.
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Sánchez-Velázquez A, Calleja-Algarra A, Velasco-Tamariz V, Zarco-Olivo C. Widespread cutaneous vasculopathy associated with levamisole-adulterated cocaine. Indian J Dermatol Venereol Leprol 2021; 87:540-542. [PMID: 34114415 DOI: 10.25259/ijdvl_986_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 01/01/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Alba Sánchez-Velázquez
- Department of Dermatology, Hospital Universitario 12 de Octubre, I+12 Research Institute, Universidad Complutense, Madrid, Spain
| | - Alba Calleja-Algarra
- Department of Dermatology, Hospital Universitario 12 de Octubre, I+12 Research Institute, Universidad Complutense, Madrid, Spain
| | - Virginia Velasco-Tamariz
- Department of Dermatology, Hospital Universitario 12 de Octubre, I+12 Research Institute, Universidad Complutense, Madrid, Spain
| | - Carlos Zarco-Olivo
- Department of Dermatology, Hospital Universitario 12 de Octubre, I+12 Research Institute, Universidad Complutense, Madrid, Spain
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Igwe CN, Robinson F, Jones SM. A novel case of ocular cicatricial pemphigoid induced by levamisole-adulterated cocaine. Eur J Ophthalmol 2021; 31:11-15. [PMID: 33884920 DOI: 10.1177/1120672120964756] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To report a case of ocular cicatricial pemphigoid caused by levamisole-adulterated cocaine. METHODS Case report. RESULTS A 54-year-old woman with multi-systemic levamisole-induced vasculitis which triggered bilateral cicatrizing conjunctivitis refractory to conventional immunosuppressants due to continued cocaine misuse. CONCLUSION Levamisole-induced vasculitis is a significant public health issue due to its popularity as an adulterant to cocaine. Our report suggests that levamisole caused vasculitis and ocular cicatricial pemphigoid in this case. Ocular manifestation of this syndrome is rare.
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Affiliation(s)
- Chinedu N Igwe
- Department of Ophthalmology, King's College Hospital, London, UK
| | - Fiona Robinson
- Department of Ophthalmology, King's College Hospital, London, UK
| | - Sophie M Jones
- Department of Ophthalmology, King's College Hospital, London, UK
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Midthun KM, Nelson LS, Logan BK. Levamisole-a Toxic Adulterant in Illicit Drug Preparations: a Review. Ther Drug Monit 2021; 43:221-228. [PMID: 33298746 DOI: 10.1097/ftd.0000000000000851] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 11/10/2020] [Indexed: 02/06/2023]
Abstract
ABSTRACT Discovered in the 1960s, the common anthelminthic levamisole has seen widespread use in veterinary applications. Its use rapidly expanded thereafter to include human medical treatments for a variety of acute and chronic disorders. Because of reports of severe adverse effects, the US Food and Drug Administration withdrew levamisole's approval for human use in 2000; however, medical options outside the United States and illicit options worldwide allow continued accessibility to levamisole. The compound is rapidly metabolized in the body, with at least 2 known active metabolites. Levamisole has a broad range of immunomodulatory effects, including both stimulatory and inhibitory effects on immune responses. It is generally well tolerated at therapeutic concentrations, although a variety of autoimmune-related adverse effects have been reported, including agranulocytosis, leukopenia, purpura, and visible necrotized skin tissue. Individuals with levamisole-compromised immune systems are more susceptible to infections, including COVID-19. Since the early 2000's, levamisole has been frequently used as an adulterating agent in illicit street drugs, especially cocaine, fentanyl, and heroin. Although its prevalence has varied over time and geographically, levamisole has been detected in up to 79% of the street supply of cocaine at levels up to 74% by weight. Its presence in illicit drug markets also raises concern over the potential for exposure of children and neonates, although this is supported by only limited anecdotal evidence. Levamisole is not currently included in routine drug testing panels, although a variety of confirmatory testing techniques exist across a range of antemortem and postmortem specimen options. Because of its varying presence in illicit drug markets, both the medical and forensic communities need to be aware of levamisole and its potential impact on toxicological investigations.
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Affiliation(s)
| | - Lewis S Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey; and
| | - Barry K Logan
- NMS Labs, Horsham, Pennsylvania
- Center for Forensic Science Research and Education (CFSRE) at the Fredric Rieders Family Foundation, Willow Grove, Pennsylvania
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A 50-Year-Old Woman With Confusion and Facial Rash. Chest 2020; 157:e37-e40. [PMID: 32033659 DOI: 10.1016/j.chest.2019.08.2207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 08/04/2019] [Accepted: 08/25/2019] [Indexed: 11/23/2022] Open
Abstract
CASE PRESENTATION A 50-year-old woman presented to the ED with a 3-day history of increasing confusion. Prior to her presentation, the patient had been in her usual state of health as reported by her family. She had a history of bipolar disorder and attention-deficit/hyperactivity disorder but had stopped her psychiatric medications for the past 4 days secondary to loss of insurance coverage. History was limited due to the patient's altered state and confusion, and was obtained from family. There was no history of headache, loss of consciousness, weakness of extremities, seizures, fever, or recent trauma. The patient's medical history also included cocaine abuse. The patient's family believed she had been abstinent from cocaine use for several years.
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Abstract
GENERAL PURPOSE To discuss the pathogenesis and clinical features of wounds caused by microthrombi formation under the following categories of systemic diseases: cold-related and immune-complex deposition diseases, coagulopathies, abnormalities in red blood cell structure, emboli, and vasospasm. TARGET AUDIENCE This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES After participating in this educational activity, the participant should be better able to:1. Recall the etiology, risk factors, and pathophysiology of the various types of microthrombotic wounds.2. Describe the clinical manifestations and treatment of the various types of microthrombotic wounds. ABSTRACT Typical wounds such as diabetic foot ulcers, venous leg ulcers, pressure ulcers, and arterial ulcers are responsible for more than 70% of chronic wounds. Atypical wounds have broad differential diagnoses and can sometimes develop as a combination of different conditions. Regardless of the etiology, impaired blood circulation is characteristic of all chronic and acute wounds. Chronic wounds associated with microthrombi formation are an important group of atypical wounds commonly linked to an underlying systemic disease. In this perspective article, the pathogenesis and clinical features of wounds caused by microthrombi formation are discussed under the following categories of systemic diseases: cold-related and immune-complex deposition diseases, coagulopathies, abnormalities in red blood cell structure, emboli, and vasospasm.
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10
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An Approach to Retiform Purpura for the Inpatient Dermatologist. CURRENT DERMATOLOGY REPORTS 2019. [DOI: 10.1007/s13671-019-00281-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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11
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Martirosyan A, Aminov R, Manukyan G. Environmental Triggers of Autoreactive Responses: Induction of Antiphospholipid Antibody Formation. Front Immunol 2019; 10:1609. [PMID: 31354742 PMCID: PMC6635959 DOI: 10.3389/fimmu.2019.01609] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 06/27/2019] [Indexed: 12/19/2022] Open
Abstract
Antiphospholipid antibodies (aPLs) comprise a diverse family of autoantibodies targeted against proteins with the affinity toward negatively charged phospholipids or protein-phospholipid complexes. Their clinical significance, including prothrombotic potential of anti-cardiolipin antibodies (aCLs), anti-β2-glycoprotein I antibodies (aβ2-GPIs), and lupus anti-coagulant (LA), is well-established. However, the ontogeny of these pathogenic aPLs remains less clear. While transient appearance of aPLs could be induced by various environmental factors, in genetically predisposed individuals these factors may eventually lead to the development of the antiphospholipid syndrome (APS). Since the first description of APS, it has been found that a wide variety of microbial and viral agents influence aPLs production and contribute to clinical manifestations of APS. Many theories attempted to explain the pathogenic potential of different environmental factors as well as a phenomenon termed molecular mimicry between β2-GPI molecule and infection-relevant structures. In this review, we summarize and critically assess the pathogenic and non-pathogenic formation of aPLs and its contribution to the development of APS.
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Affiliation(s)
- Anush Martirosyan
- Laboratory of Molecular and Cellular Immunology, Institute of Molecular Biology, Yerevan, Armenia.,Russian-Armenian (Slavonic) University, Yerevan, Armenia
| | - Rustam Aminov
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Gayane Manukyan
- Laboratory of Molecular and Cellular Immunology, Institute of Molecular Biology, Yerevan, Armenia.,Russian-Armenian (Slavonic) University, Yerevan, Armenia
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12
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Clinical Profile of Levamisole-Adulterated Cocaine-Induced Vasculitis/Vasculopathy. J Clin Rheumatol 2019; 25:e16-e26. [DOI: 10.1097/rhu.0000000000000813] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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Fiorentin TR, Fogarty M, Limberger RP, Logan BK. Determination of cutting agents in seized cocaine samples using GC–MS, GC–TMS and LC–MS/MS. Forensic Sci Int 2019; 295:199-206. [DOI: 10.1016/j.forsciint.2018.12.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 12/14/2018] [Accepted: 12/18/2018] [Indexed: 10/27/2022]
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14
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Cocaine and ANCA associated vasculitis-like syndromes – A case series. Autoimmun Rev 2018; 17:73-77. [DOI: 10.1016/j.autrev.2017.11.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 10/02/2017] [Indexed: 11/19/2022]
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15
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Marquez J, Aguirre L, Muñoz C, Echeverri A, Restrepo M, Pinto LF. Cocaine-Levamisole-Induced Vasculitis/Vasculopathy Syndrome. Curr Rheumatol Rep 2017; 19:36. [DOI: 10.1007/s11926-017-0653-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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16
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Swe T, Pervil-Ulysse M, Baqui AA. Cocaine-induced vasculitis with cutaneous manifestation: A recurrent episode after 2 years. J Family Med Prim Care 2017; 5:712-715. [PMID: 28217616 PMCID: PMC5290793 DOI: 10.4103/2249-4863.197294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Cocaine is a popular recreational drug in the United States, and up to 70% of the seized cocaine contains levamisole which is an antihelminthic that can cause cutaneous vasculitis with necrosis and positive antineutrophil cytoplasmic antibodies (ANCAs). Here, we report a unique case of recurrent cocaine-induced vasculitis in a patient who smokes cocaine for more than 20 years. A 38-year-old woman complained of painful erythematous rash in her right arm and right thigh which appeared some hours after smoking cocaine. Physical examination revealed tender, erythematous base, retiform purpura with necrosis and bullae. Serological test showed high atypical perinuclear ANCA titer of 1:320 and antimyeloperoxidase antibody level of 20.4 U/mL. Cocaine-induced vasculitis should be one of the differential diagnoses in cocaine abusers who present with painful rash and areas of necrosis. Early diagnosis is important since it is an emerging public health concern.
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Affiliation(s)
- Thein Swe
- Department of Internal Medicine, Interfaith Medical Center, Brooklyn, New York, USA
| | - Mona Pervil-Ulysse
- Division of Rheumatology, Interfaith Medical Center, Brooklyn, New York, USA
| | - Aam A Baqui
- Department of Pathology, Interfaith Medical Center, Brooklyn, New York, USA
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VASCULITE INDUZIDA POR COCAÍNA ‐ RELATO DE CASO. REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2017.07.530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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18
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Abstract
The use of cocaine continues to grow worldwide. One of the possible side-effects of cocaine is vasculitis. Two distinct vasculitic syndromes have been described due to cocaine. One is cocaine-induced midline destructive lesion, secondary to a direct vasoconstrictor effect of cocaine, inducing ischemic necrosis of the septal cartilage and perforation of the nasal septum, mimicking findings of granulomatosis with polyangiitis in the upper airways. The other is ANCA-associated vasculitis, attributed to the levamisole component that contaminates about 70% of the cocaine. This type of vasculitis may be myeloperoxidase (MPO) and proteinase 3 (PR3) positive, and its main manifestations are typical cutaneous findings, arthralgia, otolaryngologic involvement, and agranulocytosis. A high degree of suspicion and awareness is needed in order properly to diagnose and treat these patients.
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Affiliation(s)
- Mark Berman
- Department of Rheumatology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daphna Paran
- Department of Rheumatology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ori Elkayam
- Department of Rheumatology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Bajaj S, Hibler B, Rossi A. Painful Violaceous Purpura on a 44-Year-Old Woman. Am J Med 2016; 129:e5-7. [PMID: 26868857 PMCID: PMC5545122 DOI: 10.1016/j.amjmed.2016.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 01/03/2016] [Accepted: 01/05/2016] [Indexed: 11/19/2022]
Affiliation(s)
- Shirin Bajaj
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brian Hibler
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anthony Rossi
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.
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20
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Riley ED, Kral AH, Cohen J, Dilworth SE, Shumway M, Lynch KL. Levamisole-Contaminated Cocaine Use in HIV-Infected and Uninfected Unstably Housed Women. J Womens Health (Larchmt) 2016; 25:936-43. [PMID: 27203838 DOI: 10.1089/jwh.2015.5532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A growing number of case reports cite serious health complications linked to the cocaine adulterant, levamisole and women are disproportionately affected; however, the clinical effects are not well established. Between April and October of 2010, we conducted a cross-sectional study among 222 homeless and unstably housed women (116 human immunodeficiency virus [HIV]-infected and 106 HIV-uninfected). Immune markers and behavioral factors were compared in separate models by cocaine and levamisole exposure. Overall, 63% of participants were toxicology positive for cocaine/benzoylecgonine, 85% of whom also tested positive for levamisole. Differences in immune markers did not reach levels of significance among HIV-uninfected persons. Compared to HIV-infected persons who were negative for both cocaine and levamisole, the adjusted odds of low white blood cell count were significantly higher among HIV-infected persons positive for both (p = 0.03), but not for those positive for cocaine only. Neutrophil count and HIV viral load did not differ by cocaine and levamisole status among HIV-infected persons. In a separate model, the adjusted odds of testing positive for levamisole were higher among African American women compared to Caucasian and Asian women (p = 0.02). In the context of high levamisole prevalence, results suggest that decreased immune function as a result of levamisole exposure occurs mainly in individuals who are already immune compromised (e.g., HIV-positive), and race/ethnicity appears to be an important factor in understanding levamisole exposure among cocaine-using women. While larger and geographically diverse studies are needed to elucidate these initial findings, results suggest that levamisole may be one mechanism of immune dysfunction in HIV-infected cocaine-using women.
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Affiliation(s)
- Elise D Riley
- 1 Department of Medicine, University of California , San Francisco, San Francisco, California
| | - Alex H Kral
- 2 RTI International, Behavioral and Urban Health Program , San Francisco, California
| | - Jennifer Cohen
- 3 Department of Clinical Pharmacy, University of California , San Francisco, San Francisco, California
| | - Samantha E Dilworth
- 1 Department of Medicine, University of California , San Francisco, San Francisco, California
| | - Martha Shumway
- 4 Department of Psychiatry, University of California , San Francisco, San Francisco, California
| | - Kara L Lynch
- 5 Department of Laboratory Medicine, University of California , San Francisco, San Francisco, California
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21
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Veronese FV, Dode RSO, Friderichs M, Thomé GG, da Silva DR, Schaefer PG, Sebben VC, Nicolella AR, Barros EJG. Cocaine/levamisole-induced systemic vasculitis with retiform purpura and pauci-immune glomerulonephritis. ACTA ACUST UNITED AC 2016; 49:e5244. [PMID: 27119429 PMCID: PMC4849970 DOI: 10.1590/1414-431x20165244] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 03/03/2016] [Indexed: 11/29/2022]
Abstract
Levamisole has been increasingly used as an adulterant of cocaine in recent years,
emerging as a public health challenge worldwide. Levamisole-associated toxicity
manifests clinically as a systemic vasculitis, consisting of cutaneous,
hematological, and renal lesions, among others. Purpura retiform, cutaneous necrosis,
intravascular thrombosis, neutropenia, and less commonly crescentic nephritis have
been described in association with anti-neutrophil cytoplasmic antibodies (ANCAs) and
other autoantibodies. Here we report the case of a 49-year-old male who was a chronic
cocaine user, and who presented spontaneous weight loss, arthralgia, and 3 weeks
before admission purpuric skin lesions in the earlobes and in the anterior thighs.
His laboratory tests on admission showed serum creatinine of 4.56 mg/dL, white blood
count 3,800/μL, hemoglobin 7.3 g/dL, urinalysis with 51 white blood cells/μL and 960
red blood cells/μL, and urine protein-to-creatinine ratio 1.20. Serum ANCA testing
was positive (>1:320), as well as serum anti-myeloperoxidase and anti-proteinase 3
antibodies. Urine toxicology screen was positive for cocaine and levamisole, with
62.8% of cocaine, 32.2% of levamisole, and 5% of an unidentified substance. Skin and
renal biopsies were diagnostic for leukocytoclastic vasculitis and pauci-immune
crescentic glomerulonephritis, respectively. The patient showed a good clinical
response to cocaine abstinence, and use of corticosteroids and intravenous
cyclophosphamide. Last serum creatinine was 1.97 mg/dL, white blood cell count
7,420/μL, and hemoglobin level 10.8 g/dL. In levamisole-induced systemic vasculitis,
the early institution of cocaine abstinence, concomitant with the use of
immunosuppressive drugs in severe cases, may prevent permanent end organ damage and
associate with better clinical outcomes.
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Affiliation(s)
- F V Veronese
- Serviço de Nefrologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - R S O Dode
- Serviço de Nefrologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - M Friderichs
- Serviço de Nefrologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - G G Thomé
- Serviço de Nefrologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - D R da Silva
- Serviço de Nefrologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - P G Schaefer
- Serviço de Patologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - V C Sebben
- Centro de Informação Toxicológica, Fundação Estadual de Produção e Pesquisa em Saúde, Porto Alegre, RS, Brasil
| | - A R Nicolella
- Centro de Informação Toxicológica, Fundação Estadual de Produção e Pesquisa em Saúde, Porto Alegre, RS, Brasil
| | - E J G Barros
- Serviço de Nefrologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
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Recurrent Thrombotic Vasculopathy in a Former Cocaine User. Case Rep Dermatol Med 2016; 2015:763613. [PMID: 26793396 PMCID: PMC4697073 DOI: 10.1155/2015/763613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 11/26/2015] [Accepted: 12/02/2015] [Indexed: 11/17/2022] Open
Abstract
We report a case of a 35-year-old female who presented to the emergency room (ER) complaining of a pruritic rash involving multiple areas of the body. She had a significant history of cocaine use in the past. She had first developed a similar rash in 2013 when she was diagnosed with cocaine-induced vasculitis. Her urine toxicology had been positive for cocaine in the past until July 2013. She was incarcerated and attended a drug rehabilitation program after which she quit cocaine use, which was consistent with negative urine toxicology on subsequent admissions. Further workup did not reveal any other, autoimmune or infectious, etiology of this clinical presentation. The patient underwent biopsy of the skin lesion that was consistent with thrombotic vasculopathy likely secondary to levamisole.
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Necrotising glomerulonephritis in levamisole-contaminated cocaine use. Nefrologia 2015; 36:76-8. [PMID: 26620419 DOI: 10.1016/j.nefro.2015.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 03/06/2015] [Indexed: 11/20/2022] Open
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Systemic Levamisole-Induced Vasculitis in a Cocaine User without Cutaneous Findings: A Consideration in Diagnosis. Case Rep Med 2015; 2015:547023. [PMID: 26635879 PMCID: PMC4618334 DOI: 10.1155/2015/547023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 09/22/2015] [Accepted: 09/27/2015] [Indexed: 02/01/2023] Open
Abstract
Levamisole is a known immunomodulating agent frequently used as a cutting agent in cocaine consumed in the United States today. Numerous cases of anti-neutrophil cytoplasmic antibody (ANCA) vasculitis connected with the use of levamisole-adulterated cocaine have previously been reported in the literature, classically characterized by a retiform purpuric rash. We report a case of a crack-cocaine user without cutaneous abnormalities who developed ANCA-associated glomerulonephritis that progressed to renal failure. This case demonstrates the difficulties in solidifying the diagnosis of levamisole-induced vasculitis in the absence of cutaneous findings and the need to pursue more testing to establish causality in ANCA-associated vasculitis that has potential for severe end-organ damage in patients who continue to use cocaine.
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Patnaik S, Balderia P, Vanchhawng L, Markazi P, Wykretowicz J, Perloff S. Is Levamisole-Induced Vasculitis a Relegated Diagnostic Possibility? A Case Report and Review of Literature. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:658-62. [PMID: 26406869 PMCID: PMC4588636 DOI: 10.12659/ajcr.894537] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Patient: Female, 38 Final Diagnosis: Levamisole induced vasculitis Symptoms: Skin and joint Medication: — Clinical Procedure: None Specialty: Toxicology
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Affiliation(s)
- Soumya Patnaik
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA, USA
| | - Percy Balderia
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA, USA
| | - Lisa Vanchhawng
- Department of Medicine, Division of Infectious Disease, Albert Einstein Medical Center, Philadelphia, PA, USA
| | - Peyman Markazi
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA, USA
| | - Jedrzej Wykretowicz
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA, USA
| | - Sarah Perloff
- Department of Medicine, Division of Infectious Disease, Albert Einstein Medical Center, Philadelphia, PA, USA
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van der Veer T, Pennings E, Tervaert JWC, Korswagen LA. Levamisole-contaminated cocaine: a hairy affair. BMJ Case Rep 2015; 2015:bcr-2015-210970. [PMID: 26311010 DOI: 10.1136/bcr-2015-210970] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Levamisole-contaminated cocaine can induce severe systemic vasculitis. The diagnosis can be challenging, especially when substance abuse is uncertain. We present the case of a 42-year-old woman suffering from vasculitis due to levamisole-contaminated cocaine, who persistently denied substance abuse. Symptoms included ulcerating skin lesions, arthralgia and myalgia, and the occurrence of an ileal intussusception. The definitive diagnosis was made using hair testing for toxins. She recovered through cocaine abstinence, but re-exposure resulted in a severe relapse with glomerulonephritis. Importantly, at time of the relapse, the patient became positive for both myeloperoxidase-antineutrophil cytoplasmic antibody (ANCA) and proteinase 3-ANCA. Cocaine-levamisole-induced vasculitis poses a great clinical challenge. The proper diagnostic strategy and therapy is still controversial. We highlight our diagnostic and therapeutic considerations, including hair testing for definitive proof of exposure.
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Affiliation(s)
- Tjeerd van der Veer
- Department of Internal Medicine, Sint Franciscus Gasthuis, Rotterdam, The Netherlands
| | - Ed Pennings
- Department of Toxicology, Maastricht University, Maastricht, The Netherlands
| | - J W Cohen Tervaert
- SFVG Academy, Sint Franciscus Vlietland Groep, Rotterdam, the Netherlands Clinical and Experimental Immunology, Maastricht University, Maastricht, the Netherlands
| | - Lindy-Anne Korswagen
- Department of Rheumatology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands
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29
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Cocaine induced pleural and pericardial effusion syndrome. Case Rep Pulmonol 2015; 2015:321539. [PMID: 25918664 PMCID: PMC4396144 DOI: 10.1155/2015/321539] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 03/26/2015] [Indexed: 11/26/2022] Open
Abstract
A 42-year-old African American female with chronic cocaine use for 20 years, presented with two-day history of exertional shortness of breath and pleuritic chest pain. She was admitted three years back with acute kidney injury and skin rashes. At that time, skin biopsy was consistent with leukocytoclastic vasculitis and renal biopsy revealed proliferative glomerulonephritis. She responded to oral prednisone and mycophenolate with complete recovery of her kidney functions. Skin rash was waxing and waning over the last two years. On the second admission, patient was found to have large pleural effusion on computerized tomography scan and pericardial effusion on echocardiogram as shown in the figures. Pleural fluid analysis was exudative. Her serology was negative for ANA (antineutrophilic antibody) and anti-dsDNA (double stranded DNA). Complements levels were normal. She had positive low titers of ANCA levels. The patient was started on a course of prednisone for 6 months. Her pleural and pericardial effusion resolved completely on follow-up imaging with computerized tomography scan and echocardiogram. This case is unique since the pericardial and pleural effusions developed without any other etiology in the setting of cocaine; hence, we describe this clinical syndrome as cocaine induced pleural and pericardial effusions syndrome (CIPP).
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McMullin CM, Bayat I, Rytina E, See TC, Varty K, Coughlin PA. Profound acute limb ischemia affecting all four limbs following cocaine inhalation. J Vasc Surg 2015; 61:504-6. [DOI: 10.1016/j.jvs.2013.09.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Revised: 09/10/2013] [Accepted: 09/11/2013] [Indexed: 11/29/2022]
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Lawrence LA, Jiron JL, Lin HS, Folbe AJ. Levamisole-adulterated cocaine induced skin necrosis of nose, ears, and extremities: Case report. ALLERGY & RHINOLOGY 2015; 5:132-6. [PMID: 25565048 PMCID: PMC4275458 DOI: 10.2500/ar.2014.5.0101] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Levamisole is an immunomodulatory and antihelminthic drug, previously removed from the United States market, and now estimated to be present in the vast majority of cocaine distributed in the United States. Levamisole-adulterated cocaine (LAC) exposure can result in neutropenia, thrombocytopenia, and vasculitis with a predilection for subsites of the face. The objective of this review is to increase awareness among otolaryngologists of the manifestations of LAC exposure. We present the case of a 33-year-old woman with a history of cocaine use, consulted for purpuric, necrotic lesions of the nose, cheeks, and ears, with accompanying leukopenia, thrombocytopenia, and positive antineutrophil cytoplasmic antibodies (ANCA). The effects of levamisole are immune mediated, with antibodies directed against neutrophils causing neutropenia, and vasculitis caused by antibody deposition or secondary to induction of antiphospholipid antibodies causing thrombosis. LAC exposure can be differentiated from other similar appearing pathologies by evaluating serology for specific ANCA. The most important treatment is cessation of cocaine use, which most often results in complete resolution of symptoms. Awareness of the presentation, complications, and treatment of LAC exposure may be especially important for otolaryngologists, who may be one of the firsts to evaluate an affected patient.
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Affiliation(s)
- Lauren A Lawrence
- Department of Otolaryngology, Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, USA
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32
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Keith PJ, Joyce JC, Wilson BD. Pyoderma gangrenosum: a possible cutaneous complication of levamisole-tainted cocaine abuse. Int J Dermatol 2014; 54:1075-7. [DOI: 10.1111/ijd.12212] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - Joel C. Joyce
- Department of Dermatology; Medical College of Wisconsin; Milwaukee WI USA
| | - Barbara D. Wilson
- Department of Dermatology; Medical College of Wisconsin; Milwaukee WI USA
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33
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Levamisole-contaminated cocaine: an emergent cause of vasculitis and skin necrosis. Case Rep Med 2014; 2014:434717. [PMID: 24778656 PMCID: PMC3977436 DOI: 10.1155/2014/434717] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 02/17/2014] [Indexed: 02/01/2023] Open
Abstract
The prevalence of cocaine adulterated with levamisole-induced vasculitis is increasing and physicians should be aware of this unique entity. There have been many reports of cutaneous vasculitis syndrome caused by cocaine which is contaminated with levamisole. Levamisole was used as an antihelminth drug and later was rescinded from use in humans due to adverse effects. Through this paper, we will report a 39-year-old crack cocaine user who presented with purpuric rash and skin necrosis of his ear lobes. Levamisole-induced vasculitis syndrome was suspected. A urine toxicology screen was positive for cocaine, opiates, and marijuana. Blood work revealed positive titres of ANA and p-ANCA, as well as anti-cardiolipin antibody. Biopsy taken from the left ear showed focal acute inflammation, chronic inflammation with thrombus formation, and extravasated blood cells. Treatment was primarily supportive with wound care.
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34
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Gastroenterology cases of cutaneous leukocytoclastic vasculitis. Case Rep Med 2013; 2013:264189. [PMID: 24250337 PMCID: PMC3819799 DOI: 10.1155/2013/264189] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 09/04/2013] [Accepted: 09/09/2013] [Indexed: 01/17/2023] Open
Abstract
Rarely, leukocytoclastic vasculitis can result from ischemic colitis, inflammatory bowel disease, and cryoglobulinemia. There is no established standard for the treatment of leukocytoclastic vasculitis associated with gastroenterologic diseases. This paper presents three cases of leukoytoclastic vasculitis, each of which is associated with a different gastroenterologic condition: ischemic colitis, Crohn's disease, and chronic hepatitis C. Each condition went into remission by treatment of leukocytoclastic vasculitis, regardless of the underlying disease.
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35
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James KT, Detz A, Coralic Z, Kanzaria H. Levamisole contaminated cocaine induced cutaneous vasculitis syndrome. West J Emerg Med 2013; 14:448-9. [PMID: 24106539 PMCID: PMC3789905 DOI: 10.5811/westjem.2013.3.16184] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Accepted: 03/25/2013] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kellee T James
- University of California San Francisco, Department of Clinical Pharmacy, San Francisco, California
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36
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García Pérez MR, Ortiz-González VL, Betancourt M, Mercado R. Cocaine-induced vasculitis: is this a new trend? Open Access Rheumatol 2013; 5:77-80. [PMID: 27790026 PMCID: PMC5074789 DOI: 10.2147/oarrr.s51524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Cocaine-induced vasculitis is a rare complication found in drug abusers. It occurs due to cocaine adulterated with levamisole. Levamisole was once used as a chemotherapy and immunomodulator for different conditions. One of the side effects of this medication is necrotizing vasculitis which has been reported in the US and Puerto Rico. Here we present another case of cocaine induced vasculitis in Puerto Rico. We describe a 43-year-old female with past medical history of bronchial asthma, migraine, and crack smoking who presented to the emergency room due to blood in her urine for 5 days. She also reported fever, chills, and fatigue. At the physical exam she had a right knee ulcer with swelling erythema, warmth, and pain. Also, she had retiform purpuric plaque lesions in her ears, bilaterally. Eroded plaques with elevated borders at left foot and finger dorsum were also present. Laboratory workup was positive for cocaine. The patient showed leucopenia and microcytic anemia with a normal absolute neutrophil count in her cell blood count. Blood cultures, urine cultures, and ulcer cultures were negative. Urinalysis was positive for proteinuria and hematuria. Also, the patient had positive perinuclear anti-neutrophil cytoplasmic antibody, cytoplasmic anti-neutrophil cytoplasmic antibody, and antinuclear antibody tests and elastase specificity. She showed negative anticardiolipin and lupus anticoagulant antibodies. Her complement levels were decreased. The punch biopsy of her ear showed superficial thrombosis of superficial vascular plexus with perivascular lymphocytic infiltrates and deeper sections showed epidermal necrosis and necrotizing vasculitis. She was started on a high dose of steroids, but could not complete the treatment because she escaped from the hospital before finishing her treatment.
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Affiliation(s)
| | | | | | - Rogelio Mercado
- Department of Dermatology, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
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Jackson BS, Cannon CM. Rash from levamisole vasculopathy in a cocaine abuser. J Emerg Med 2013; 45:e45-7. [PMID: 23777775 DOI: 10.1016/j.jemermed.2013.03.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 03/28/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Bradley S Jackson
- Department of Emergency Medicine, University of Kansas Medical Center, Kansas City, Kansas 66160, USA
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Abstract
PURPOSE OF REVIEW Cocaine use is associated with several rheumatic syndromes. This review summarizes these clinical manifestations and highlights recent developments linked to levamisole-adulterated cocaine. RECENT FINDINGS Cocaine use has been linked to several distinctive syndromes that can be difficult to distinguish from idiopathic rheumatic diseases. These disorders can range in severity from purely cosmetic damage to organ and/or life-threatening disease that includes sinonasal destruction and vasculitis. Many of these illnesses are associated with antineutrophil cytoplasmic antibodies (cytoplasmic, perinuclear and atypical perinuclear patterns). With the recent introduction of levamisole as a cocaine adulterant, a newly reported syndrome has emerged that is associated with neutropenia, retiform purpura with cutaneous necrosis and autoantibodies consisting of high-titre perinuclear antineutrophil cytoplasmic antibodies (p-ANCAs) with specificities for 'atypical' antigens. SUMMARY Cocaine use is associated with clinical syndromes that closely mimic other primary rheumatic diseases. Given the high prevalence of cocaine use and its adulteration with levamisole, clinicians should be familiar with these rheumatic manifestations in order to avoid misdiagnosis and unnecessary treatment with potentially toxic therapies.
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Abstract
Secondary vasculitis is a form of vasculitis for which an underlying disease is known. Diseases associated with secondary vasculitis include infections, drug hypersensitivity, malignancy, rheumatoid arthritis, collagen vascular disease and sarcoidosis. Moreover, there are numerous conditions that can mimic vasculitis clinically, in laboratory testing, radiographically and in histopathology. It is evident that distinguishing primary vasculitis from secondary vasculitis and also vascular inflammation from non-vasculitic disorders (vasculitis mimics) has significant therapeutic implications.
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Affiliation(s)
- K de Groot
- Med Klinik III (Nephrologie, Hypertensiologie, Rheumatologie), Klinikum Offenbach GmbH, Offenbach, Deutschland
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Abstract
Levamisole-contaminated cocaine is an increasingly reported cause of a syndrome characterized by vasculitic skin lesions and immunologic abnormalities. With approximately 70% of cocaine in the United States now contaminated with levamisole, the incidence of this syndrome is likely to increase. We report two cases of this syndrome and review its clinical presentation, course, and prognosis.
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Affiliation(s)
- Raghad Abdul-Karim
- Department of Internal Medicine, Baylor University Medical Center at Dallas (Abdul-Karim, Ryan, Emmett); and the University of Texas Southwestern Medical School, Dallas (Rangel). From the Division of Gastroenterology, Department of Internal Medicine (Mantas), and the Department of Transplant Hepatology (Wells, Trotter), Baylor University Medical Center at Dallas
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Wollina U, Unger L, Haroske G, Heinig B. Classification of vascular disorders in the skin and selected data on new evaluation and treatment. Dermatol Ther 2013; 25:287-96. [PMID: 22950555 DOI: 10.1111/j.1529-8019.2012.01514.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Cutaneous vascular disorders are common. They include arteries, veins, and lymphatic vessels, or a mixture of them. In this review, we discuss classification, new developments in understanding and treatment of vascular diseases. We focus on infantile hemangiomas and drug therapy, vasculitides with new vasculitic syndromes, yellow nail syndrome and localized lymphatic malformations. Benign cutaneous vascular lesions may be a sign of severe internal diseases. In many cases multidisciplinary treatment is important. The dermatologist can often act as a pilot for these patients.
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Affiliation(s)
- Uwe Wollina
- Department of Dermatology and Allergology, Academic Teaching Hospital Dresden-Friedrichstadt, Dresden, Germany.
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Pavenski K, Vandenberghe H, Jakubovic H, Adam DN, Garvey B, Streutker CJ. Plasmapheresis and Steroid Treatment of Levamisole-Induced Vasculopathy and Associated Skin Necrosis in Crack/Cocaine Users. J Cutan Med Surg 2013; 17:123-8. [DOI: 10.2310/7750.2012.12028] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Levamisole was removed from the market due to complications of agranulocytosis and skin necrosis. Levamisole has been reported in a high proportion of seized cocaine in North America and has been associated with multiple cases of skin necrosis. Objective: We report three cases of levamisole/cocaine-induced skin necrosis who responded to treatment with plasmapheresis and immunosuppression. Results: Three patients presented with painful necrotic skin lesions on the ears, cheeks, breasts, and buttocks. The extremities were involved in two patients and the upper respiratory tract mucosa in one patient. All had markers of immune activation, with elevated C-reactive protein, antinuclear antibody, and perinuclear antineutrophil cytoplasmic antibody. Skin biopsy in all cases revealed a mixed pattern of thrombosis and vasculitis within dermal vessels, with overlying ischemic ulceration of skin and soft tissues. One patient required extensive debridement of the skin and soft tissue of the calves and also had respiratory involvement. All patients were treated with plasmapheresis and immunosuppression with rapid stabilization and/or improvement of the lesions. Conclusion: Levamisole is frequently added to crack/cocaine; we report three patients who developed vascular lesions and skin necrosis after using cocaine/levamisole. These improved with plasmapheresis and immunosuppression as well as abstention from the drugs; one patient with severe disease required debridement and skin grafting.
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Affiliation(s)
- Katerina Pavenski
- From the Divisions of Transfusion Medicine, Biochemistry, and Pathology, Department of Laboratory Medicine, Li Ka Shing Knowledge Institute, St. Michael's Hospital; Department of Laboratory Medicine and Pathobiology, University of Toronto; Department of Dermatology, St. Michael's Hospital; and Department of Medicine (Hematology), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
| | - Hilde Vandenberghe
- From the Divisions of Transfusion Medicine, Biochemistry, and Pathology, Department of Laboratory Medicine, Li Ka Shing Knowledge Institute, St. Michael's Hospital; Department of Laboratory Medicine and Pathobiology, University of Toronto; Department of Dermatology, St. Michael's Hospital; and Department of Medicine (Hematology), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
| | - Henry Jakubovic
- From the Divisions of Transfusion Medicine, Biochemistry, and Pathology, Department of Laboratory Medicine, Li Ka Shing Knowledge Institute, St. Michael's Hospital; Department of Laboratory Medicine and Pathobiology, University of Toronto; Department of Dermatology, St. Michael's Hospital; and Department of Medicine (Hematology), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
| | - David N. Adam
- From the Divisions of Transfusion Medicine, Biochemistry, and Pathology, Department of Laboratory Medicine, Li Ka Shing Knowledge Institute, St. Michael's Hospital; Department of Laboratory Medicine and Pathobiology, University of Toronto; Department of Dermatology, St. Michael's Hospital; and Department of Medicine (Hematology), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
| | - Bernadette Garvey
- From the Divisions of Transfusion Medicine, Biochemistry, and Pathology, Department of Laboratory Medicine, Li Ka Shing Knowledge Institute, St. Michael's Hospital; Department of Laboratory Medicine and Pathobiology, University of Toronto; Department of Dermatology, St. Michael's Hospital; and Department of Medicine (Hematology), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
| | - Catherine J. Streutker
- From the Divisions of Transfusion Medicine, Biochemistry, and Pathology, Department of Laboratory Medicine, Li Ka Shing Knowledge Institute, St. Michael's Hospital; Department of Laboratory Medicine and Pathobiology, University of Toronto; Department of Dermatology, St. Michael's Hospital; and Department of Medicine (Hematology), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
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Abstract
BACKGROUND Levamisole has recently been implicated as a cause of cutaneous vasculopathy in cocaine abusers. The objective of this study was to describe this relatively new entity by reviewing published cases identified through a literature search. METHODS Published reports identified through a search of PubMed database (from 1964 to November 2011) were reviewed to record clinical, serological and pathologic findings. RESULTS A cohort of 32 patients had a mean age of 44 ± 9 years with a female predominance (75%). Rash predominately affected lower extremities (87.5%), followed by face (78%) and ears (69%) and typically presented as purpuric plaques, which were seen in a retiform pattern in 16 (50%) and had central necrosis in 11 patients (34%). Leukopenia and neutropenia were found in 20 patients (63%). Antinuclear cytoplasmic antibody (ANCA) was positive in 30 patients (94%); p-ANCA in 28 patients (87.5%), c-ANCA in 19 (59%) and both in 17 patients (53%). Skin biopsy results were available for 29 patients: 14 (48%) had pure thrombotic vasculopathy, 4 (14%) had pure small vessel vasculitis and 11 (38%) had evidence of both. Treatment information was available for 30 patients. Only supportive care was given to 11 patients (37%), steroids to 16 (53%) and surgical treatment for 5 (17%). Clinical course of lesions was available for 24 patients. Rash resolved in 11 patients (46%) and improved in 13 (54%). During median follow-up of 21 days (range, 7-270 days), 10 of 22 patients had recurrences related to cocaine use. CONCLUSION Levamisole-induced cutaneous vasculopathy in cocaine users is characterized by a female predominance, a retiform purpuric rash with a predilection for lower extremities, autoantibody production, leukopenia and/or neutropenia and recurrences with future cocaine use.
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Abstract
We report a case of cutaneous vasculopathy associated with the use of levamisole-adulterated cocaine. This recently described clinical entity is characterized by a purpuric rash with a predilection for the ears, leukopenia, and anti-neutrophilic cytoplasmic antibody (ANCA) positivity. It is estimated that more than 70% of the current United States cocaine supply is contaminated with levamisole. Levamisole is a widely available, inexpensive, white powder used as a "cutting agent" in cocaine to expand volume and increase profits. It may also increase the euphoric and stimulatory effects of cocaine by increasing brain dopamine levels and producing amphetamine-like metabolites. Our patient exhibited a characteristic rash with involvement of the ears, leukopenia, and cocaine metabolites were detected in serum and urine. The presence of levamisole was confirmed in the urine utilizing gas chromatography-mass spectrometry. ANCA positivity was also present. Punch biopsy of the skin demonstrated vascular thrombosis and necrosis without true vasculitis. We review the literature for reported cases of cocaine-levamisole cutaneous vasculopathy syndrome, highlight the salient immunologic abnormalities, and contrast the features of this entity with idiopathic systemic vasculitis.
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Affiliation(s)
- Huy Tran
- Internal Medicine Residency Program, Department of Medicine, St. Elizabeth Health Center, Youngstown, Ohio, USA
| | - Debbie Tan
- Internal Medicine Residency Program, Department of Medicine, St. Elizabeth Health Center, Youngstown, Ohio, USA
| | - Thomas P. Marnejon
- Internal Medicine Residency Program, Department of Medicine, St. Elizabeth Health Center, Youngstown, Ohio, USA
- Department of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, USA
- Corresponding Author: Thomas Marnejon, DO Department of Medicine St. Elizabeth Health Center 1044 Belmont Avenue Youngstown, OH 44501 Tel: (330) 480-3344 Fax: (330) 480-3777
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45
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Magliocca KR, Coker NA, Parker SR. The head, neck, and systemic manifestations of levamisole-adulterated cocaine use. J Oral Maxillofac Surg 2013; 71:487-92. [PMID: 23298805 DOI: 10.1016/j.joms.2012.10.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 10/29/2012] [Indexed: 11/26/2022]
Abstract
Systemic complications of levamisole-adulterated cocaine (LAC) use have recently been described. The objective of this review is to increase awareness of these manifestations among oral and maxillofacial surgeons. LAC exposure through inhalation, nasal insufflation, or injection can induce cutaneous vasculopathy and hematologic abnormalities such as neutropenia or agranulocytosis. Unlike other vasculopathies involving the skin, LAC-induced vascular injury frequently manifests with purpuric and necrotic lesions that involve the face and ears. Oral manifestations have also been reported but are not yet well characterized. The aforementioned hematologic manifestations are not uncommon, and patients exposed to LAC are potentially at higher risk for infectious complications. When manifestations of LAC affect the head, neck, and oral cavity, oral and maxillofacial surgeons may be the first providers to encounter the patient. Early recognition of the clinical signs and laboratory abnormalities will better allow for distinguishing LAC-related effects from various clinical mimics, will facilitate appropriate patient management, and may further contribute to the understanding of the biological effects of LAC.
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Affiliation(s)
- Kelly R Magliocca
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA 30322, USA.
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Massera D, Bachhuber M, Shen L, Karambelkar A. Vasculitis in a cocaine user. BMJ Case Rep 2012; 2012:bcr-2012-007379. [PMID: 23144356 DOI: 10.1136/bcr-2012-007379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Daniele Massera
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
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47
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Gulati S, Donato AA. Lupus anticoagulant and ANCA associated thrombotic vasculopathy due to cocaine contaminated with levamisole: a case report and review of the literature. J Thromb Thrombolysis 2012; 34:7-10. [PMID: 22437653 DOI: 10.1007/s11239-012-0711-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
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.
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Affiliation(s)
- Shuchi Gulati
- Department of Internal Medicine, The Reading Hospital and Medical Center, 6th Avenue and Spruce Street, West Reading, PA 19611, USA.
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48
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Arora NP, Jain T, Bhanot R, Natesan SK. Levamisole-induced leukocytoclastic vasculitis and neutropenia in a patient with cocaine use: an extensive case with necrosis of skin, soft tissue, and cartilage. Addict Sci Clin Pract 2012. [PMID: 23186390 PMCID: PMC3509389 DOI: 10.1186/1940-0640-7-19] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Levamisole-induced vasculitis is a relatively new entity in people who use cocaine. We describe a 44-year-old woman with a history of cocaine use who presented with a complaint of a painful rash of 2-3 month’s duration on her extremities, cheeks, nose, and earlobes. She had not experienced fever, weight loss, alopecia, dry eyes, oral ulcers, photosensitivity, or arthralgia. Examination revealed tender purpuric eruptions with central necrosis on her nose, cheeks, earlobes, and extremities. Laboratory investigations revealed neutropenia, an elevated erythrocyte sedimentation rate (ESR), presence of lupus anticoagulant, low complement component 3 (C3), and presence of perinuclear anti-neutrophil cytoplasmic antibody (p-ANCA). A urine toxicology screen was positive for cocaine, and gas chromatography–mass spectrometry was positive for levamisole. Skin biopsy showed leukocytoclastic vasculitis and small vessel thrombosis. Necrotic lesions of the nose led to its self-amputation. Large bullae on the lower extremities ruptured, leading to wound infection and extensive necrosis that required multiple surgical debridements. When necrosis progressed despite debridement, bilateral above-knee amputation of the legs was performed. Once new lesions stopped appearing, the patient was discharged home. Two months later, she had a recurrence related to cocaine use. To the best of our knowledge, this is only the second reported case of levamisole-induced vasculitis that required above-knee amputation.
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Affiliation(s)
- Natasha Purai Arora
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit Medical Center, 4201 Saint Antoine Street, Detroit, 48201 MI, USA.
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49
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Lazareth H, Peytavin G, Polivka L, Dupin N. The hairy-print for levamisole-induced vasculitis. BMJ Case Rep 2012; 2012:bcr-2012-006602. [PMID: 22879002 DOI: 10.1136/bcr-2012-006602] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Levamisole-induced vasculitis is a well-characterised antineutrophil cytoplasm antibodies (ANCA)-positive vasculitis in cocaine abuser patients. However, due to the short half-life of levamisole in serum and urine, the causal role of levamisole is not established. Here we report the detection of both levamisole and cocaine in hair samples of a patient who presented with an ANCA-positive vasculitis. The higher concentration of levamisole in proximal sample of the hair confirms that the patient abused of cocaine added with levamisole in the days preceding the development of skin lesions. Although a direct causative role has not been established, our report strongly suggests that levamisole may have triggered vasculitis in this case.
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Affiliation(s)
- Hélène Lazareth
- Service de Dermatologie, Université Paris Descartes, Pavillon Tarnier, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
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50
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Belfonte CD, Shanmugam VK, Kieffer N, Coker S, Boucree S, Kerr G. Levamisole-induced occlusive necrotising vasculitis in cocaine abusers: an unusual cause of skin necrosis and neutropenia. Int Wound J 2012; 10:590-6. [PMID: 22716045 DOI: 10.1111/j.1742-481x.2012.01027.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
We present three cases describing the various skin manifestations of presumed levamisole-contaminated cocaine use. Antibody-mediated vasculitis and neutropenia were consistent findings in these cases and repeat exposure resulted in distinct dermatologic complications. This phenomenon of levamisole-induced vasculitis and neutropenia is being increasingly described and has characteristic wound manifestations that must be recognised and treated early.
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Affiliation(s)
- Cassius D Belfonte
- Division of Cardiology, Howard University Hospital, Washington, DC, USA Division of Rheumatology, Immunology and Allergy, Georgetown University Hospital, Washington, DC, USA Division of Rheumatology, Veterans Affairs Hospital, Washington, DC, USA Department of Internal Medicine, Howard University Hospital, Washington, DC, USA
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