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Xu X, Tsai M, Xiao N, Tan X, Zhang F, Yu Y, Wang Q, Xie W, Wang H, Li D. Fatal spontaneous rupture of common iliac artery associated with fibromuscular dysplasia. Forensic Sci Res 2017; 4:358-363. [PMID: 32002496 PMCID: PMC6968554 DOI: 10.1080/20961790.2016.1274467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 12/15/2016] [Indexed: 11/26/2022] Open
Abstract
A previously healthy 25-year-old man with no known risk factors was presented at the emergency room with a 3 h history of abdominal and loin pain. Physical examination and lab data showed no specific findings except tenderness, slight white cell count elevation and decreased haemoglobin level. The patient's condition deteriorated over the following hours and he died despite resuscitation attempts. Autopsy revealed a 2.5-cm longitudinal tear in the intima of the right common iliac artery, which formed a thrombosed false lumen extending to the abdominal aorta proximally and to the left common iliac artery. Histopathologic examination revealed the characteristic changes of fibromuscular dysplasia (FMD). FMD involving the common iliac arteries is extremely rare; only six cases have been reported previously, and only two of those included forensic findings. The presented case is the first case of FMD with intimal tearing in the right common iliac artery, with propagation to the left common iliac artery and abdominal aorta. When a previously healthy young adult without hypertension or other risk factors presents with acute abdominal and loin pain, systemic vascular disease should be on the list of differential diagnoses. Careful and complete evaluation of multiple arteries can be critical.
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Affiliation(s)
- Xiang Xu
- School of Forensic Medicine, Southern Medical University, Guangzhou, China.,School of Forensic Medicine, Wannan Medical College, Wuhu, China
| | - Mengchen Tsai
- Department of Forensic Medicine, College of Medicine, National Taiwan University, Taipei, China
| | - Ning Xiao
- School of Forensic Medicine, Southern Medical University, Guangzhou, China
| | - Xiaohui Tan
- School of Forensic Medicine, Southern Medical University, Guangzhou, China
| | - Fu Zhang
- Guangdong Public Security Department, Key Lab of Forensic Pathology, Guangzhou, China
| | - Yangeng Yu
- Guangdong Public Security Department, Key Lab of Forensic Pathology, Guangzhou, China
| | - Qi Wang
- School of Forensic Medicine, Southern Medical University, Guangzhou, China
| | - Weibing Xie
- School of Forensic Medicine, Southern Medical University, Guangzhou, China
| | - Huijun Wang
- School of Forensic Medicine, Southern Medical University, Guangzhou, China
| | - Dongri Li
- School of Forensic Medicine, Southern Medical University, Guangzhou, China
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2
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Tokatli A, Tatli E, Aksoy M, Cakar MA. Cholesterol embolization syndrome after primary percutaneous coronary intervention in patient with acute anterior myocardial infarction. INTERNATIONAL JOURNAL OF THE CARDIOVASCULAR ACADEMY 2016. [DOI: 10.1016/j.ijcac.2016.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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3
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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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Fowler AH, Majithia V. Ultimate mimicry: methamphetamine-induced pseudovasculitis. Am J Med 2015; 128:364-6. [PMID: 25498165 DOI: 10.1016/j.amjmed.2014.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 12/01/2014] [Accepted: 12/01/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Amanda H Fowler
- Division of Rheumatology, Department of Medicine, University of Mississippi Medical Center, Jackson.
| | - Vikas Majithia
- Division of Rheumatology, Department of Medicine, University of Mississippi Medical Center, Jackson; Division of Rheumatology, Department of Medicine, GV (Sonny) Montgomery Veterans Affairs Medical Center, Jackson
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5
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Altun A, Altun G, Olcaysu OO, Kurna SA, Aki SF. Central retinal artery occlusion in association with fibromuscular dysplasia. Clin Ophthalmol 2013; 7:2253-5. [PMID: 24293990 PMCID: PMC3839843 DOI: 10.2147/opth.s55011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
A 14 year-old female, whose chief complaint was severe vision loss in the right eye for 2 days, presented to the Clinic of Ophthalmology of Fatih Sultan Mehmet Education and Research Hospital. The patient had been attending follow-up visits for 4 years, following a diagnosis of fibromuscular dysplasia by the Clinic of Pediatrics. The patient underwent a complete ophthalmo-logic, angiographic, hematologic, and systemic evaluation. Fundus fluorescein angiography was performed immediately, because of the cherry-red spot sign in the macula of the right eye. Fundus fluorescein angiography revealed evidence of marked stasis of the retinal arterial circulation in the right eye. Best corrected visual acuity was 20/400 in the right eye and 20/20 in the left eye.
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Affiliation(s)
- Ahmet Altun
- Clinic of Ophthalmology, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
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6
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Seemann A, De Prost N, Paoletti MT, Sbidian E, Brun-Buisson C, Valeyrie-Allanore L. Vascular purpura revealing a severe dilated cardiomyopathy with left ventricular apical thrombus. J Cardiovasc Dis Res 2012; 3:326-8. [PMID: 23233780 PMCID: PMC3516016 DOI: 10.4103/0975-3583.102724] [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: 12/02/2022] Open
Abstract
We present a case of vascular purpura revealing an intra-cardiac left-sided thrombus complicating an end-stage dilated cardiomyopathy. Vascular purpura main etiologies encompass the wide specturm of vasculitides and microvascular-occlusion syndromes. Among them, cardiac embolism represents an unusal but potentially severe etology.
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Affiliation(s)
- Aurélien Seemann
- Service de Réanimation médicale, Assistance Publique - Hôpitaux de Paris, Hôpital Henri Mondor, Créteil, France
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7
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Khan TA, Cuchacovich R, Espinoza LR, Lata S, Patel NJ, Garcia-Valladares I, Salassi MM, Sanders CV. Vasculopathy, hematological, and immune abnormalities associated with levamisole-contaminated cocaine use. Semin Arthritis Rheum 2012; 41:445-54. [PMID: 22152487 DOI: 10.1016/j.semarthrit.2011.04.010] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 04/27/2011] [Accepted: 04/29/2011] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Tahir A Khan
- Section of Rheumatology, LSU Health Sciences Center, New Orleans, LA, USA
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Walsh NMG, Green PJ, Burlingame RW, Pasternak S, Hanly JG. Cocaine-related retiform purpura: evidence to incriminate the adulterant, levamisole. J Cutan Pathol 2010; 37:1212-9. [PMID: 20738457 DOI: 10.1111/j.1600-0560.2010.01613.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The term 'cocaine-induced pseudovasculitis' was coined to encompass a constellation of clinical and laboratory findings which mimics a systemic vasculitis but lacks confirmatory evidence of vasculitis on biopsy. Antineutrophil cytoplasmic antibodies reacting with human neutrophil elastase (HNE) have been reported to distinguish the cocaine-related syndrome from a true autoimmune vasculitis. Published cases of retiform purpura related to cocaine use are rare and an etiologic role for levamisole, a common adulterant of cocaine, has been postulated. We describe two female patients aged 39 and 49 years with cocaine-related retiform purpura, mainly affecting the legs. The initial clinical and serological profile in case 1 led to a suspicion of anti-phospholipid syndrome and in case 2 to Wegener's granulomatosis with an unexplained associated neutropenia. Skin biopsies revealed a mixed pattern of leukocytoclastic vasculitis and microvascular thrombosis in case 1 and pure microvascular thrombosis in case 2. Identification of anti-HNE antibodies in both patients linked their disease to cocaine. The mixed vasculopathic pattern in case 1 and the associated neutropenia in case 2, both known adverse effects of levamisole, point to this as the true etiologic agent. Urine toxicology shortly after a binge of cocaine use in each case was positive for levamisole.
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Affiliation(s)
- Noreen M G Walsh
- Department of Pathology, Capital District Health Authority and Dalhousie University, 5788 University Avenue, Halifax, Nova Scotia, Canada.
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Abstract
Vasculitis often presents a diagnostic challenge as the disease processes may have varied presentations. This article reviews some vasculitis-like "mimics," particularly emphasizing viral and bacterial infections, drug-related disorders, various malignancies, and other autoimmune disorders, all of which may have a similar clinical presentation. This article also highlights recent advances and the importance of accurate diagnosis and therapy.
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10
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Herrero C, Guilabert A, Mascaró-Galy J. Livedo reticularis de las piernas: Metodología de diagnóstico y tratamiento. ACTAS DERMO-SIFILIOGRAFICAS 2008. [DOI: 10.1016/s0001-7310(08)74756-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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11
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Herrero C, Guilabert A, Mascaró-Galy J. Diagnosis and Treatment of Livedo Reticularis on the Legs. ACTAS DERMO-SIFILIOGRAFICAS 2008. [DOI: 10.1016/s1578-2190(08)70327-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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12
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Konttinen YT, Pettersson T, Matucci-Cerinic M, Dadoniene J, Poduval P. Roadmap to vasculitis: a rheumatological treasure hunt. INDIAN JOURNAL OF RHEUMATOLOGY 2007. [DOI: 10.1016/s0973-3698(10)60039-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Abstract
Cutaneous pseudovasculitis represents a heterogeneous collection of disorders that are capable of simulating cutaneous vasculitis and can be broadly classified into diseases that produce hemorrhage (petechiae, purpura, and ecchymoses) or vessel occlusion with resultant livedo, cyanosis, ulcers, digital necrosis, and/or gangrene. Overlap is not uncommon, but if present, one mechanism dominates. Hemorrhagic pseudovasculitis is due to vessel wall dysfunction (incompetence), which can be related to diverse factors that include vessel wall deposition of metabolic substances (amyloid, calcium), nutritional deficiencies (scurvy), nonvasculitic inflammatory purpura (pigmented purpuric dermatitis, arthropod, viral and drug reactions), degeneration of the vessel wall and supporting stroma (senile/solar purpura), direct vessel wall invasion of infective organisms, coagulation-fibrinolytic disorders (eg, thrombocytopenia), and vessel wall trauma. Cyanotic-infarctive pseudovasculitis is due vaso-occlusion by emboli, thrombi, or fibrointimal hyperplasia (endarteritis obliterans) and includes varied conditions such as purpura fulminans, Coumadin necrosis, antiphospholipid antibody syndrome, cardiac myxoma, cholesterol embolization, calciphylaxis, and radiation arteritis. Delayed and inappropriate diagnosis of pseudovasculitis leads to incorrect management and exposure to potentially deleterious treatment modalities such as corticosteroids and cytotoxic agents. The diagnosis of a pseudovasculitic disorder requires a high index of suspicion and should always be part of the differential diagnosis of vasculitis. Skin biopsy is a crucial step in differentiating pseudovasculitis from authentic vasculitis; absence of histologic evidence of vasculitis, particularly after multiple biopsies, should direct evaluation and diagnosis towards pseudovasculitis.
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Affiliation(s)
- J Andrew Carlson
- Division of Dermatology, Albany Medical College, Albany, NY 12208, USA.
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14
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Abstract
Vasculitis presents several diagnostic challenges. Firstly, patients could present with protean clinical manifestations with a wide spectrum ranging from isolated cutaneous vasculitis to multisystem involvement. Secondly, there are several medical conditions that could mimic the presentation of vasculitis. The range of differential diagnosis is therefore broad. Thirdly, vasculitis could occur as a primary disorder or be secondary to various medical conditions. It becomes important to differentiate them, as treatment of some forms of vasculitis such as those that are secondary to infection or drugs, is different from that of primary vasculitis. Fourthly, there are several different forms of vasculitis. Some are benign and self limiting, while others have the potential to threaten vital organ function and life. It follows that a rational approach is required during evaluation of patients with suspected vasculitis.
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Affiliation(s)
- E Suresh
- Rheumatology Department, Kettering General Hospital, Rothwell Road, Kettering NN16 8UZ, UK.
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15
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Abstract
Vasculitis is histologically defined as inflammatory cell infiltration and destruction of blood vessels. Vasculitis is classified as primary (idiopathic, eg, cutaneous leukocytoclastic angiitis, Wegener's granulomatosis) or secondary, a manifestation of connective tissue diseases, infections, adverse drug eruptions, or a paraneoplastic phenomenon. Cutaneous vasculitis, manifested as urticaria, purpura, hemorrhagic vesicles, ulcers, nodules, livedo, infarcts, or digital gangrene, is a frequent and often significant component of many systemic vasculitic syndromes such as lupus or rheumatoid vasculitis and antineutrophil cytoplasmic antibody-associated primary vasculitic syndromes such as Churg-Strauss syndrome. In most instances, cutaneous vasculitis represents a self-limited, single-episode phenomenon, the treatment of which consists of general measures such as leg elevation, warming, avoidance of standing, cold temperatures and tight fitting clothing, and therapy with antihistamines, aspirin, or nonsteroidal anti-inflammatory drugs. More extensive therapy is indicated for symptomatic, recurrent, extensive, and persistent skin disease or coexistence of systemic disease. For mild recurrent or persistent disease, colchicine and dapsone are first-choice agents. Severe cutaneous and systemic disease requires more potent immunosuppression (prednisone plus azathioprine, methotrexate, cyclophosphamide, cyclosporine, or mycophenolate mofetil). In cases of refractory vasculitis, plasmapheresis and intravenous immunoglobulin are viable considerations. The new biologic therapies that work via cytokine blockade or lymphocyte depletion such as tumor alpha inhibitor infliximab and the anti-B-cell antibody rituximab, respectively, are showing benefit in certain settings such as Wegener's granulomatosis, antineutrophil cytoplasmic antibody-associated vasculitis, Behçet's disease, and cryoglobulinemic vasculitis.
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Affiliation(s)
- J Andrew Carlson
- Division of Dermatology, Albany Medical College, MC-81, NY 12208, USA.
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Abstract
We describe a case of cardiac myxoma whose clinical presentation mimicked that of polyarteritis nodosa. The serum levels of MPO-ANCA and IL-6 were elevated on laboratory investigation and normalized after the removal of the tumor. We suggest that a 'true' vasculitic mechanism contributes to the pathogenesis of pseudovasculitis in cardiac myxoma.
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Affiliation(s)
- Y Nishio
- Department of Neurology, Jikei University Kashiwa Hospital, Kashiwa, Japan.
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17
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Ribi C, Mauget D, Egger JF, Khatchatourian G, Villard J. Pseudovasculitis and corticosteroid therapy. Clin Rheumatol 2005; 24:539-43. [PMID: 16003589 DOI: 10.1007/s10067-004-1080-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2004] [Accepted: 11/09/2004] [Indexed: 10/25/2022]
Abstract
Pseudovasculitis, vasculitis-like syndromes, vasculitis look-alikes, or mimics of vasculitis represent a heterogeneous collection of disorders that are capable of simulating vasculitis. Inappropriate diagnosis leads to delay or absence of proper management and exposure to potentially deleterious treatment modalities such as corticosteroids and cytotoxic agents. We report the case of fibromuscular dysplasia suspected to be a polyarteritis nodosa. The progression of the lesions visualized by the ultrasonographic study and computed tomography (CT) scan after 10 days of treatment led to an emergency laparotomy. The possible deleterious role of steroids given to treat the suspected vasculitis is discussed.
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Affiliation(s)
- Camillo Ribi
- Immunology and Transplant Unit, Service of Immunology and Allergology, Geneva University Hospital, 24, rue Micheli-du-Crest, 1211, Geneva 4, Switzerland
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Abstract
Pseudovasculitis is a disease process that mimics the presentation and possibly the laboratory findings of true vasculitis. However, biopsy specimens do not reveal the typical histopathologic findings expected in vasculitis. One often overlooked cause of pseudovasculitis is cocaine use, which has been described in case reports to cause aggressive nasal destruction and various skin lesions and thus has been confused with Wegener granulomatosis or leukocytoclastic vasculitis. Unfortunately, serologic tests such as antinuclear antibody or antineutrophil cytoplasmic antibody cannot reliably differentiate between these entities. We describe a patient who presented with what was believed to be Wegener granulomatosis affecting the skin and upper airway. However, findings from repeated biopsies did not support this diagnosis, and the only unifying diagnosis was cocaine-induced pseudovasculitis. The ability to recognize and differentiate between true vasculitis and pseudovasculitis is essential for the clinician because treatment options are radically disparate.
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Affiliation(s)
- Daphne R Friedman
- Department of Medicine, University of Maryland Medical Center, Baltimore, MD 21201, USA.
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Affiliation(s)
- Alejandro Olivé
- Sección de Reumatología. Hospital Universitario Germans Trias i Pujol. Badalona. Barcelona. España.
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