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Alexander-Savino CV, Mirowski GW, Culton DA. Mucocutaneous Manifestations of Recreational Drug Use. Am J Clin Dermatol 2024; 25:281-297. [PMID: 38217568 DOI: 10.1007/s40257-023-00835-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2023] [Indexed: 01/15/2024]
Abstract
Recreational drug use is increasingly common in the dermatology patient population and is often associated with both general and specific mucocutaneous manifestations. Signs of substance use disorder may include changes to general appearance, skin, and mucosal findings associated with particular routes of drug administration (injection, insufflation, or inhalation) or findings specific to a particular drug. In this review article, we provide an overview of the mucocutaneous manifestations of illicit drug use including cocaine, methamphetamine, heroin, hallucinogens, marijuana, and common adulterants to facilitate the identification and improved care of these patients with the goal being to connect this patient population with appropriate resources for treatment.
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Affiliation(s)
- Carolina V Alexander-Savino
- State University of New York Upstate Medical University, Syracuse, NY, USA
- Department of Dermatology, University of North Carolina at Chapel Hill, 410 Market Street, Suite 400, Chapel Hill, NC, 27516, USA
| | - Ginat W Mirowski
- Department of Dermatology, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Oral Pathology, Medicine, Radiology, Indiana University School of Dentistry, Indianapolis, IN, USA
| | - Donna A Culton
- Department of Dermatology, University of North Carolina at Chapel Hill, 410 Market Street, Suite 400, Chapel Hill, NC, 27516, USA.
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2
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Recurrent Antineutrophil Cytoplasmic Antibody-Associated Vasculitis Induced by Levamisole-Adulterated Cocaine. Am J Dermatopathol 2021; 43:443-445. [PMID: 33156021 DOI: 10.1097/dad.0000000000001837] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT Levamisole, an anthelmintic and immunomodulatory drug, was withdrawn from the US market in 1999 due to adverse effects, including agranulocytosis and vasculitis. In recent years, levamisole has been used as a common cocaine adulterant, and its use has led to an autoimmune syndrome characterized by an antineutrophil cytoplasmic antibody-associated vasculitis presenting with necrotic retiform purpura on the face and extremities. We present a case of recurrent levamisole-induced vasculitis initially misdiagnosed as systemic lupus erythematosus to highlight this easily misdiagnosed entity and to demonstrate re-exposure leading to recurrent vasculitis with more extensive clinical manifestations.
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Abstract
Levamisole is a veterinary antihelminthic, chemotherapeutic agent, and immunomodulator that also is used as an adulterant and cutting agent in cocaine distribution. This drug may potentiate the sympathomimetic actions of cocaine and can cause neutropenia, agranulocytosis, purpuric retiform lesions, and skin necrosis. This article describes two cases of suspected levamisole-induced vasculitis. No standardized diagnostic or treatment algorithm exists for this challenging condition. Diagnosis and treatment require a multidisciplinary team approach.
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Abstract
Aminorex (5-phenyl-4,5-dihydro-1,3-oxazol-2-amine) and 4-methylaminorex (4-methyl-5-phenyl-4,5-dihydro-1,3-oxazol-2-amine) are psychostimulants that have long been listed in Schedules IV and I of the UN Convention on Psychotropic Substances of 1971. However, a range of psychoactive analogues exist that are not internationally controlled and therefore often classified as new psychoactive substances (NPS). Aminorex analogues encompass failed pharmaceuticals that reemerged as drugs of abuse, and newly synthesized substances that were solely designed for recreational use by clandestine chemists. NPS, sometimes also referred to as "designer drugs" in alignment with a phenomenon arising in the early 1980s, serve as alternatives to controlled drugs. Aminorex and its derivatives interact with monoaminergic neurotransmission by interfering with the function of monoamine transporters. Hence, these compounds share pharmacological and neurochemical similarities with amphetamines and cocaine. The consumption of aminorex, 4-methylaminorex and 4,4'-dimethylaminorex (4-methyl-5-(4-methylphenyl)-4,5-dihydro-1,3-oxazol-2-amine) has been associated with adverse events including death, bestowing an inglorious fame on aminorex-derived drugs. In this Review, a historical background is presented, as well as an account of the pharmacodynamic and pharmacokinetic properties of aminorex and various analogues. Light is shed on their misuse as drug adulterants of well-established drugs on the market. This Review not only provides a detailed overview of an abused substance-class, but also emphasizes the darkest aspect of the NPS market, i.e., deleterious side effects that arise from the ingestion of certain NPS, as knowledge of the pharmacology, the potency, or the identity of the active ingredients remains obscure to NPS users.
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Affiliation(s)
- Julian Maier
- Medical University of Vienna, Center for Physiology and Pharmacology, Institute of Pharmacology, Währingerstraße 13A, 1090, Vienna, Austria
| | - Felix P. Mayer
- Medical University of Vienna, Center for Physiology and Pharmacology, Institute of Pharmacology, Währingerstraße 13A, 1090, Vienna, Austria
| | - Simon D. Brandt
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Byrom Street, Liverpool, L3 3AF, UK
| | - Harald H. Sitte
- Medical University of Vienna, Center for Physiology and Pharmacology, Institute of Pharmacology, Währingerstraße 13A, 1090, Vienna, Austria
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Dewan AK, Pinard J, Jadeja S, Granter S, Merola JF. Erythema elevatum diutinum-like vasculitis secondary to cocaine adulterated with levamisole. Clin Exp Dermatol 2018; 43:494-496. [PMID: 29423942 DOI: 10.1111/ced.13392] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2017] [Indexed: 11/27/2022]
Affiliation(s)
- A K Dewan
- Department of Dermatology, Brigham and Women's Hospital, Boston, MA, USA
| | - J Pinard
- Department of Dermatology, Brigham and Women's Hospital, Boston, MA, USA
| | - S Jadeja
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - S Granter
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - J F Merola
- Department of Dermatology, Brigham and Women's Hospital, Boston, MA, USA
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de Cambourg G, Mahé A, Banea S, Moulinas C, Blaison G. Granulomatose avec polyangéite révélée par une ulcération cutanée mimant un pyoderma gangrenosum : à propos de 2 cas. Rev Med Interne 2016; 37:632-5. [DOI: 10.1016/j.revmed.2015.12.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 07/31/2015] [Accepted: 12/07/2015] [Indexed: 11/28/2022]
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Le Garff E, Tournel G, Becquart C, Cottencin O, Dupin N, Delaporte E, Hedouin V. Extensive Necrotic Purpura in Levamisole-Adulterated Cocaine Abuse - A Case Report. J Forensic Sci 2016; 61:1681-1685. [PMID: 27500987 DOI: 10.1111/1556-4029.13176] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 01/26/2016] [Accepted: 01/30/2016] [Indexed: 11/28/2022]
Abstract
Levamisole, which is used as an adulterated compound of cocaine, is currently being seen year after year in cocaine intoxication. For a few cases in the last decade, necrotic purpura and neutropenia after levamisole/cocaine intoxication have been described in the medical community. Herein, we present an original case of levamisole intoxication of a 40-year-old woman who smoked heroin and cocaine few during a month. She rapidly presented an extensive necrotic purpura of the nose, cheeks and extremities (lower and upper), and immunologic reactions (positive anti-MPO and anti-HNE). Levamisole was detected on hairs with ultra-high performance liquid chromatography and tandem mass spectrometry. The case reports also a probable cocaine supplier deceit, which bring pure drug for hospital investigation after the intoxication of his client. The intoxicated woman had survived with several skin and chronic pain complications. That case recalls the knowledge about levamisole with a short review of the forensic literature.
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Affiliation(s)
- Erwan Le Garff
- Service de Médecine Légale, CHU Lille, University Lille, UTML 7367, F-59000, Lille, France
| | - Gilles Tournel
- Service de Médecine Légale, CHU Lille, University Lille, UTML 7367, F-59000, Lille, France.,Service de toxicologie, CHU Lille, University Lille, F-59000, Lille, France
| | - Coralie Becquart
- Service de dermatologie, CHU Lille, University Lille, F-59000, Lille, France
| | - Olivier Cottencin
- ScaLab CNRS UMR 9193, Service d'addictologie, CHU Lille, University Lille, F-59000, Lille, France
| | - Nicolas Dupin
- Service de dermatologie, CHU Cochin, Rue du Faubourg St Jacques, 75014, Paris, France
| | - Emmanuel Delaporte
- Service de dermatologie, CHU Lille, University Lille, F-59000, Lille, France
| | - Valéry Hedouin
- Service de Médecine Légale, CHU Lille, University Lille, UTML 7367, F-59000, Lille, France
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Imbernón-Moya A, Chico R, Aguilar-Martínez A. [Cutaneous and mucosal manifestations associated with cocaine use]. Med Clin (Barc) 2016; 146:544-9. [PMID: 27033438 DOI: 10.1016/j.medcli.2016.02.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 02/03/2016] [Accepted: 02/04/2016] [Indexed: 10/22/2022]
Abstract
Complications due to cocaine are a public health problem. The typical cutaneous disease is leukocytoclastic vasculitis and/or thrombotic vasculopathy affecting mainly the ears. No intense systemic involvement is usually present, but there may be several cutaneous, mucosal and systemic manifestations. Other findings associated as arthralgia, neutropaenia or agranulocytosis, low titer positive antinuclear antibodies, antiphospholipid antibody positivity and neutrophil cytoplasmic antibodies against multiple antigens help the diagnosis. This disease requires a clinical suspicion with a clinical history, a complete physical examination and a broad differential diagnosis for an early and correct diagnosis. The course is usually self-limited. In most cases the only treatment is to discontinue the use of cocaine associated with symptomatic treatment, no proven benefit of systemic corticosteroids.
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Affiliation(s)
- Adrián Imbernón-Moya
- Servicio de Dermatología, Hospital Universitario Severo Ochoa, Leganés, Madrid, España.
| | - Ricardo Chico
- Servicio de Dermatología, Hospital Universitario Severo Ochoa, Leganés, Madrid, España
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Jeong HS, Layher H, Cao L, Vandergriff T, Dominguez AR. Pyoderma gangrenosum (PG) associated with levamisole-adulterated cocaine: Clinical, serologic, and histopathologic findings in a cohort of patients. J Am Acad Dermatol 2016; 74:892-8. [PMID: 26785804 DOI: 10.1016/j.jaad.2015.11.040] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 11/26/2015] [Accepted: 11/30/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Recently, isolated reports of pyoderma gangrenosum (PG) secondary to levamisole-contaminated cocaine have been described, with similar serologic findings to the vasculopathic presentation. OBJECTIVE We sought to describe clinical, histopathological, and serologic findings in 8 patients with PG associated with levamisole-contaminated cocaine. METHODS Eight consecutive patients presenting with this disease spanning the period from 2011 to 2015 were included for the cohort. Observed variables included: lesion distribution, morphology, serologic titers, and histopathologic evaluation for vasculitis and vasculopathy. RESULTS All patients reported cocaine exposure prior to the onset of lesions resembling PG. Lesions appeared primarily on the upper (6 of 8 patients) and lower (all 8 patients) extremities. Most patients demonstrated elevated titers for p-ANCA and antiphospholipid antibodies, and a diffuse dermal infiltrate dominated by neutrophils was seen in all biopsy specimens. Lesions improved or remained stable with conservative management or short courses of steroids, and recurrence was only noted on re-exposure to adulterated cocaine. LIMITATIONS The study is limited by sample size. CONCLUSIONS PG may occur after exposure to levamisole-adulterated cocaine. Clinical and histopathological findings resemble those seen in conventional forms of PG, whereas serologic findings mirror those seen in other levamisole-associated vasculopathic or vasculitic eruptions. Cocaine avoidance represents a cornerstone of management in these patients.
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Affiliation(s)
- Haneol S Jeong
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Heather Layher
- Brooke Army Medical Center, San Antonio Uniformed Services Health Education Consortium, Dermatology Residency Program, San Antonio, Texas
| | - Lauren Cao
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Travis Vandergriff
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Arturo R Dominguez
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas.
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Clinical Comorbidities among Cocaine Users Screened in the Community through HealthStreet. HEALTH BEHAVIOR AND POLICY REVIEW 2016; 3:54-61. [PMID: 27030823 DOI: 10.14485/hbpr.3.1.6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES We investigated the differences in clinical characteristics and musculoskeletal (MSK) conditions by cocaine use. METHODS HealthStreet, a community engagement program assessed 7936 adults for medical conditions. RESULTS Among 6145 African Americans (77%) and 1791 (23%) Caucasians, 15.5 % and 25% reported cocaine use, respectively. African-American cocaine users were older (p < .001) and more likely to report hypertension (p < .001) and HIV (p <.001) than Caucasian users. Compared to non-users, back pain was reported by 42% of African Americans (p < .001) and 48% of Caucasian cocaine users (p < .003). African-American cocaine users had significantly higher odds of back pain, 1.60 (95% CI 1.27, 2.04) and arthritis, 1.40 (95% CI 1.19, 1.64) than Caucasians. CONCLUSIONS Cocaine users are more likely to endorse MSK conditions than non-users. Racial disparities among users existed; however, how race affects health among users requires further research.
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12
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Levamisole/Cocaine Induced Systemic Vasculitis and Immune Complex Glomerulonephritis. Case Rep Nephrol 2015; 2015:372413. [PMID: 26290761 PMCID: PMC4531184 DOI: 10.1155/2015/372413] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 07/14/2015] [Indexed: 11/17/2022] Open
Abstract
Levamisole is an antihelminthic and immunomodulator medication that was banned by the USFDA in 1998. It has been increasingly used to adulterate cocaine due to its psychotropic effects and morphological properties. Adverse reactions including cutaneous vasculitis, thrombocytopenia, and agranulocytosis have been well described. Despite systemic vasculitis in this setting, renal involvement is uncommon. We report here a case of ANCA positive systemic vasculitis with biopsy proven immune complex mediated glomerulonephritis likely secondary to levamisole/cocaine. A 40-year-old Caucasian male with no past medical history presented with 3-week history of fatigue, skin rash, joint pains, painful oral lesions, oliguria, hematuria, worsening dyspnea on exertion, and progressive lower extremity edema. He had a history of regular tobacco and cocaine use. Lab testing revealed severe anemia, marked azotemia, deranged electrolytes, and 4.7 gm proteinuria. Rheumatologic testing revealed hypocomplementemia, borderline ANA, myeloperoxidase antibody, and positive atypical p-ANCA. Infectious and other autoimmune workup was negative. Kidney biopsy was consistent with immune mediated glomerulonephritis and showed mesangial proliferation and immune complex deposition consisting of IgG, IgM, and complement. High dose corticosteroids and discontinuing cocaine use resulted in marked improvement in rash, mucocutaneous lesions, and arthritis. There was no renal recovery and he remained hemodialysis dependent.
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Buxton JA, Omura J, Kuo M, Ross C, Tzemis D, Purssell R, Gardy J, Carleton B. Genetic determinants of cocaine-associated agranulocytosis. BMC Res Notes 2015; 8:240. [PMID: 26070312 PMCID: PMC4467676 DOI: 10.1186/s13104-015-1219-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 06/01/2015] [Indexed: 11/25/2022] Open
Abstract
Background Drug-induced agranulocytosis is a recognized adverse drug event associated with serious infectious complications. Levamisole is an antihelminthic and immunomodulator withdrawn from North American markets in 2005 after reports of agranulocytosis. Previous studies of levamisole, suggest that the human leukocyte antigen (HLA)-B27 confers a genetic predisposition to this adverse drug event. Since 2009, emergency room visits due to agranulocytosis in individuals consuming levamisole-adulterated crack-cocaine have increased. Methods We performed a case–control study using a genotyping assay and novel gene chip to test the association between cocaine-associated agranulocytosis (CAA) and HLA-B27 and to identify pharmacokinetic and pharmacodynamic gene variants associated with the phenotype. Results Fifty-one CAA cases were identified through a provincial physician reporting system between 2008 and 2011. We examined eight of these cases and 26 matched controls. Genotyping revealed a significant association between HLA-B27 and CAA (odds ratio [OR] 9.2, 95% confidence interval [CI], 1.54–54.6). We also observed a similar association with the HLA-B27 tag single nucleotide polymorphism rs4349859 (OR 9.2, 95% CI 1.5–54.6) and rs13202464 (OR 6.7, 95% CI 1.1–41). Further associations were identified with variants in the ARBCC12 (OR 10.0, 95% CI 2.7–36.8) and CYP11A1 (OR 7.4, 95% CI 2.1–26.6) genes, while a novel protective association was observed with variants in the ARDB1 gene (OR 0.06, 95% CI 0.007–0.46). Conclusions We confirmed the association of HLA-B27 with CAA and identified additional susceptibility variants. Health care providers should inform people who are identified as having CAA that it is genetically determined and can recur with continued cocaine use. The severity of infections and subsequent hospitalization, and the risk of recurrence may prompt health-promoting behaviour changes of the affected individuals. These genetic associations warrant the attention of public health and knowledge translation efforts to highlight the implications for susceptibility to this severe adverse drug event.
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Affiliation(s)
- Jane A Buxton
- BC Center for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada. .,School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada.
| | - John Omura
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada.
| | - Margot Kuo
- BC Center for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada.
| | - Colin Ross
- Child and Family Research Institute, 950 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada.
| | - Despina Tzemis
- BC Center for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada.
| | - Roy Purssell
- Drug and Poison Information Centre, BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada.
| | - Jennifer Gardy
- BC Center for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada. .,School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada.
| | - Bruce Carleton
- Child and Family Research Institute, 950 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada.
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Miner J, Gruber P, Perry TL. Early excision and grafting, an alternative approach to the surgical management of large body surface area levamisole-adulterated cocaine induced skin necrosis. Burns 2014; 41:e34-40. [PMID: 25529269 DOI: 10.1016/j.burns.2014.10.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 10/31/2014] [Indexed: 11/25/2022]
Abstract
Levamisole-adulterated cocaine as a cause of retiform purpura progressing to full-thickness skin necrosis was first documented in 2003 and currently comprises over 200 reported cases. Whereas, its presentation, pathophysiology, and diagnostic workup have been reasonably well-defined, only one publication has significantly detailed its surgical management. For this reason there exists a relative absence of data in comparison to its reported incidence to suggest a preferred treatment strategy. In the case mentioned, treatment emphasized delayed surgical intervention while awaiting lesion demarcation and the monitoring of autoantibodies. At our institution we offer an alternative approach and present the case of a 34 year old female who presented with 49% TBSA, levamisole-induced skin necrosis managed with early surgical excision and skin grafting. The patient presented three days following cocaine exposure with painful, purpura involving the ears, nose, buttocks, and bilateral lower extremities which quickly progressed to areas of full-thickness necrosis. Lab analysis demonstrated elevated p-ANCA and c-ANCA, as well as leukopenia, decreased C4 complement, and urinalysis positive for levamisole, corroborating the diagnosis. Contrasting the most thoroughly documented case in which the patient underwent first surgical excision on hospital day 36 and underwent 18 total excisions, our patient underwent first excision on hospital day 10 and received only one primary excision prior to definitive autografting. To our knowledge, this is the largest surface area surgically treated that did not result in surgical amputation or autoamputation of limbs or appendages, respectively. We contend that early excision and grafting provides optimal surgical management of this syndrome while avoiding the morbidity seen with delayed intervention.
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Affiliation(s)
- Jason Miner
- Wright State University Department of Surgery, Division of Burns and Wounds at Miami Valley Hospital Regional Burn and Wound Center, One Wyoming St., Dayton, OH 45409, United States; Unites States Air Force, United States
| | - Paul Gruber
- Wright State University Department of Surgery, Division of Burns and Wounds at Miami Valley Hospital Regional Burn and Wound Center, One Wyoming St., Dayton, OH 45409, United States
| | - Travis L Perry
- Wright State University Department of Surgery, Division of Burns and Wounds at Miami Valley Hospital Regional Burn and Wound Center, One Wyoming St., Dayton, OH 45409, United States.
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