Levamisole-induced vasculitis

Cutaneous Pedal Manifestations in Patient With Hepatitis C Virus-Associated Cryoglobulinemia: Case Report and Review of Literature

Cryoglobulinemia is an uncommon blood dyscrasia that can manifest itself in the lower extremity. Due to the insidious nature of this disease, dermatological symptoms and ulcerations can easily be mistaken for more common entities. The authors present an overview of cryoglobulinemia and a case report of a patient with lower extremity manifestations of this disorder. This can provide specific guidance on the steps necessary to accurately establish the diagnosis of cryoglobulinemia or rule it out and pursue other etiologies causing lower extremity ulceration.

Acute Spinal Cord Ischemia Associated With Cocaine Use: A Case Report

Cocaine is one of the most common causes of acute drug-related emergency department visits in the United States. It produces a dose-dependent increase in heart rate and blood pressure accompanied by increased arousal and a sense of self-confidence, euphoria, and well-being. Its use is typically followed by a craving for more of the drug. It can also lead to acute events such as myocardial infarction, seizures, and cerebrovascular events. Here, we present a case of cocaine-induced spinal cord ischemia resulting in quadriplegia. Our case highlights that, in a young patient presenting with acute non-traumatic myelopathy, it is important to consider cocaine use among other differentials.

Cocaine and Levamisole Induced Vasculitis

Levamisole adulterated cocaine is a rare cause of anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis. It is increasingly diagnosed because of raised awareness; however, it is still underdiagnosed in part because of its rarity and patients not reporting cocaine use. Here we report a case of levamisole-induced vasculitis. We present a 48-year-old non-Hispanic white male with a past medical history significant for Crohn’s Disease and pneumonia who presented with acute bilateral ear pain and rash. His urinary drug screen was positive, which prompted suspicion of contamination and potential levamisole adulterated cocaine-associated vasculitis. A punch biopsy showed evidence of leukocytoclastic vasculitis and multiple fibrin thrombi further supporting contamination with levamisole. We believe this case highlights the importance of using patient history in guiding diagnostic testing in the setting of acute vasculitis. Once the history of illicit substance use was confirmed, our differential diagnosis and considerations for treatment significantly changed. 

A novel case of ocular cicatricial pemphigoid induced by levamisole-adulterated cocaine

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.

A Unique Presentation of Levamisole-Induced Antineutrophil- Cytoplasmic-Antibody-Positive Vasculitis Presenting as Inflammatory Orbitopathy

A 35-year-old woman with a history of cocaine abuse presented with progressively worsening OS pain. Neuroimaging revealed a 3-cm ill-defined left orbital lesion involving the intraconal and extraconal spaces. The orbital mass was biopsied via an anterior orbitotomy approach. Pathology demonstrated prominent angiocentric granulomatous and lymphoplasmacytic inflammation consistent with vasculitis. Laboratory tests were significant for neutropenia, positive perinuclear antineutrophil cytoplasmic antibodies with high titer, and positive myeloperoxidase antibodies, consistent with levamisole-induced vasculitis. To the authors' knowledge, this is the first reported case of cocaine-levamisole-induced vasculitis presenting as orbitopathy.

A 50-Year-Old Woman With Confusion and Facial Rash

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.

Nasal reconstructive surgery for vasculitis affecting the nose: our two-centre international experience

PURPOSE

To recommend an international multidisciplinary medical and surgical algorithm of treatment in nasal vasculitis, which will create a more streamlined approach.

METHODS

A two-centre, international retrospective analysis of granulomatosis with polyangiitis (GPA) and levamisole-associated vasculitis (LAV) cases presenting between 2005 and 2019 was carried out. Demographic data, and surgical and medical treatment were recorded. Patients' signs and symptoms were analysed, and recommended treatment strategies outlined with key surgical procedures described.

RESULTS

Forty-one GPA patients and 11 LAV patients were included in the study with a mean age of 38.6 and 38.8 years, respectively. A stepwise surgical management approach with reconstructive options is described and includes: (1) examination under general anaesthesia, biopsy, and insertion of silastic nasal splints; (2) septal perforation repair (with caution); (3) mild-to-moderate saddle nose reconstruction with costal cartilage; (4) severe saddle nose reconstruction with osseocartilaginous rib grafts; (5) soft-tissue reconstruction techniques.

CONCLUSIONS

The management of nasal vasculitis is a particular challenge in facial plastic surgery. It requires a close collaborative approach with a physician skilled in the medical management of vasculitis. Surgery must be planned judiciously, with realistic patient expectations and only after a sustained period of remission. For more severe saddle deformities, the modified osseocartilaginous Andrews technique gives excellent long-term results.

A case series and literature review on patients with rhinological complications secondary to the use of cocaine and levamisole

BACKGROUND

Levamisole is an increasingly common cutting agent used with cocaine. Both cocaine and levamisole can have local and systemic effects on patients.

METHODS

A retrospective case series was conducted of patients with a cocaine-induced midline destructive lesion or levamisole-induced vasculitis, who presented to a Dundee hospital or the practice of a single surgeon in Paisley, from April 2016 to April 2019. A literature review on the topic was also carried out.

RESULTS

Nine patients from the two centres were identified. One patient appeared to have levamisole-induced vasculitis, with raised proteinase 3, perinuclear antineutrophil cytoplasmic antibodies positivity and arthralgia which improved on systemic steroids. The other eight patients had features of a cocaine-induced midline destructive lesion.

CONCLUSION

As the use of cocaine increases, ENT surgeons will see more of the complications associated with it. This paper highlights some of the diagnostic issues and proposes a management strategy as a guide to this complex patient group. Often, multidisciplinary management is needed.

Multiple cutaneous and mucosal lesions in a patient with cocaine-levamisole-induced vasculopathy syndrome

Levamisole is an adulterant found in nearly 70% of cocaine in the United States. The concomitant use of levamisole and cocaine leads to a distinct clinical syndrome that typically manifests as agranulocytosis, leukocytoclastic vasculitis, and elevated antineutrophil cytoplasmic antibody (ANCA) levels. Systemic involvement has also been rarely reported with this syndrome. This is a case of a 51-year-old woman with chronic cocaine use who initially presented with multiple cutaneous ulcerations and was later found to have pulmonary and renal involvement. Infectious workup was unrevealing and autoimmune workup revealed highly elevated levels of perinuclear ANCA. Due to continuous cocaine use despite counseling, the patient was readmitted with worsening pulmonary and renal manifestations requiring initiation of immunosuppressive therapy.

Levamisole-Induced Vasculitis in the Lower Extremities: A Case Report

BACKGROUND

Since 2006 there have been increased reports of severe agranulocytosis and vasculitis associated with levamisole use. Historically, levamisole was an immunomodulatory agent used in various cancer treatments in the United States. Currently the drug is used as an antihelminthic veterinary medication, but it is also used as an additive in freebase cocaine. There are multiple reports of levamisole-induced vasculitis in the head and neck but limited reported cases in the lower extremities. This article describes a 60-year-old woman who presented to the emergency department with multiple painful lower-extremity ulcerations.

RESULTS

Radiographs, laboratory studies, and punch biopsy were performed. Physical examination findings and laboratory results were negative for signs of infection. Treatment included local wound care and education on cocaine cessation, and the patient was transferred to a skilled nursing facility. Her continued use of cocaine, however, prevented her ulcers from healing.

CONCLUSIONS

Local wound care and cocaine cessation is the optimal treatment for levamisole-induced lesions. With the increase in the number of patients with levamisole-induced vasculitis, podiatric physicians and surgeons would benefit from the immediate identification of these ulcerations, as their appearance alone can be distinct and pathognomonic. Early identification of levamisole-induced ulcers is important for favorable treatment outcomes. A complete medical and social history is necessary for physicians to treat these lesions with local wound care and provide therapy for patients with addictions.

Differentiation of Cocaine-Induced Midline Destructive Lesions from ANCA-Associated Vasculitis

INTRODUCTION

Cocaine-induced midline destructive lesions (CIMDL) are complications of regular nasal cocaine inhalation. CIMDL can mimic systemic diseases with positive anti-neutrophil cytoplasmic antibodies (ANCA), such as granulomatosis with polyangiitis (GPA).

CASE REPORT

In this article, we describe the case of a young woman who presented with nasal perforation induced by cocaine, along with positive perinuclear ANCA test (proteinase 3 antigen), misdiagnosed as limited GPA. The patient was treated with immunosuppressive therapy, which partially improved her symptoms. Admittance of cocaine use aided in the diagnosis of CIMDL. This patient was advised to stop cocaine use. Three-month follow-up revealed no further complications.

CONCLUSION

Considering the seropositivity of ANCA in both CIMDL and GPA, early diagnosis of CIMDL and its differentiation from GPA is crucial, and clinicians play an important role in this regard. Lack of distinct histologic characteristics of vasculitis or unresponsiveness to standard therapeutic regimens may favor the diagnosis of CIMDL syndrome. It is crucial to recognize that these conditions may have similar presentations, so that undesired and potentially toxic treatments can be prevented.

Systematic review of nephrotoxicity of drugs of abuse, 2005-2016

BACKGROUND

The United States is faced with an unprecedented epidemic of drug abuse. Every year thousands of Americans visit the emergency departments all over the country with illicit drug related complaints. These drugs have been known to be associated with a range of renal pathologies, from reversible acute kidney injuries to debilitating irreversible conditions like renal infarction. So far, no comprehensive study or systematic review has been published that includes the commonly used street drugs and designer drugs with potential nephrotoxic outcomes.

METHODS

We conducted a systematic review of published case reports, case series, and cross sectional studies of nephrotoxicities related to drugs of abuse. Literature review was conducted using PubMed/Medline from January 1, 2005 -December 31, 2016 to search for publications related to drug abuse with a defined renal outcome. Publications which reported renal injury in relation to the use of illicit drugs were selected, specifically those cases with raised creatinine levels, clinically symptomatic patients, for instance those with oliguria and proven renal biopsies.

RESULTS

A total of 4798 publications were reviewed during the search process and PRISMA flow chart and Moose protocol regarding systematic reviews were followed. 110 articles were shortlisted for the review. A total of 169 cases from case reports and case series, and 14 case studies were analyzed. Renal manifestations of specific illicit drug abuse were included in this review.

CONCLUSION

Based on the evidence presented, a wide range of renal manifestations were found to be associated with drug abuse. If the trend of increasing use of illicit drug use continues, it will put a significant percentage of the population at an elevated risk for poor renal outcomes. This study is limited by the nature of the literature reviewed being primarily case reports and case series.

Vanishing vasculitis: a case of acute necrotic skin findings without pathologic features of vasculitis from adulterated cocaine

While the usage of illicit drugs in itself carries significant health risks and associated toxicities, drugs that are adulterated to give them volume, alter their psychogenic properties, and make them cheaper to produce are to be considered even more dangerous. Cocaine is one of them, and it is now most commonly being adulterated with levamisole. We report a case of a 37-year-old female with the chief complaint of painful skin lesions and wounds on both of her upper and lower extremities for three weeks duration. She was tested positive for cocaine and had classical purpuric, ecchymotic, and necrotic patches on both ears, which are pathognomonic. She also had multiple wounds in extremities. The cocaine–levamisole related syndrome comprises a set of immunological abnormalities, out of which, ANCA positivity is the most important one. Our patient was ANCA positive. Regarding pathological findings in cocaine adulterated with levamisole syndrome, this can range from the classic finding of leukocytoclastic vasculitis of small vessels to occlusive vascular disease without true vasculitis. Our case’s biopsy showed no vasculitis, and this is why it is important to highlight that cocaine can also cause a pseudo-vasculitic picture. The other possibility that we entertained was that of pyoderma gangrenosum as the skin finding in levamisole-contaminated cocaine, and the lesion was consistent in appearance. Recently, there have been a few case reports of pyoderma gangrenosum from adulterated cocaine with levamisole, where skin findings were consistent with pyoderma gangrenosum; however, serological findings rather favored levamisole vasculopathy or vasculitis. Therefore, we should familiarize ourselves with the multitude of pathological and skin findings that adulterated cocaine can cause and, finally, make ourselves aware that the classical pathological finding of vasculitis in such cases is not always seen.

Recurrent Thrombotic Vasculopathy in a Former Cocaine User

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.

Is Levamisole-Induced Vasculitis a Relegated Diagnostic Possibility? A Case Report and Review of Literature

Patient: Female, 38

Final Diagnosis: Levamisole induced vasculitis

Symptoms: Skin and joint

Medication: —

Clinical Procedure: None

Specialty: Toxicology

Cocaine-induced vasculitis: is this a new trend?

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.