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Bettacchioli E, Foulquier JB, Chevet B, Cornec-Le Gall E, Hanrotel C, Lanfranco L, de Moreuil C, Lambert Y, Dueymes M, Foulquier N, Cornec D. Dual MPO/PR3 ANCA positivity and vasculitis: insights from a 7-cases study and an AI-powered literature review. Rheumatology (Oxford) 2024; 63:2557-2568. [PMID: 38552316 DOI: 10.1093/rheumatology/keae170] [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: 11/14/2023] [Accepted: 02/21/2024] [Indexed: 09/05/2024] Open
Abstract
OBJECTIVES Anti-neutrophil cytoplasm antibodies (ANCA)-associated vasculitides (AAV) are rare conditions characterized by inflammatory cell infiltration in small blood vessels, leading to tissue necrosis. While most patients with AAV present antibodies against either myeloperoxidase (MPO) or proteinase 3 (PR3), rare cases of dual positivity for both antibodies (DP-ANCA) have been reported, and their impact on the clinical picture remains unclear. The goal of this study was to investigate the clinical implications, phenotypic profiles and outcomes of patients with DP-ANCA. METHODS A retrospective screening for DP-ANCA cases was conducted at Brest University Hospital's immunology laboratory (France), analysing ANCA results from March 2013 to March 2022. Clinical, biological, imaging, and histological data were collected for each DP-ANCA case. Additionally, a comprehensive literature review on DP-ANCA was performed, combining an artificial intelligence (AI)-based search using BIBOT software with a manual PUBMED database search. RESULTS The report of our cases over the last 9 years and those from the literature yielded 103 described cases of patients with DP-ANCA. We identified four distinct phenotypic profiles: (i) idiopathic AAV (∼30%); (ii) drug-induced AAV (∼25%); (iii) autoimmune disease associated with a low risk of developing vasculitis (∼20%); and (iv) immune-disrupting comorbidities (infections, cancers, etc) not associated with AAV (∼25%). CONCLUSION This analysis of over a hundred DP-ANCA cases suggests substantial diversity in clinical and immunopathological presentations. Approximatively 50% of DP-ANCA patients develop AAV, either as drug-induced or idiopathic forms, while the remaining 50%, characterized by pre-existing dysimmune conditions, demonstrates a remarkably low vasculitis risk. These findings underscore the complex nature of DP-ANCA, its variable impact on patient health, and the necessity for personalized diagnostic and management approaches in these cases.
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Affiliation(s)
- Eléonore Bettacchioli
- Immunology and Immunotherapy Laboratory, CHU de Brest, Brest, France
- LBAI Inserm UMR 1227, Univ Brest, Brest, France
| | | | | | - Emilie Cornec-Le Gall
- Nephrology Department, CHU de Brest, Brest, France
- GGB Inserm UMR 1078, Univ Brest, Brest, France
| | | | | | - Claire de Moreuil
- Internal Medicine Department, CHU de Brest, Brest, France
- GETBO Inserm UMR 1304, Univ Brest, Brest, France
| | - Yannick Lambert
- Internal Medicine Department, Morlaix Hospital Centre, Morlaix, France
| | - Maryvonne Dueymes
- Immunology and Immunotherapy Laboratory, CHU de Brest, Brest, France
- LBAI Inserm UMR 1227, Univ Brest, Brest, France
| | | | - Divi Cornec
- LBAI Inserm UMR 1227, Univ Brest, Brest, France
- Rheumatology Department, CHU de Brest, Brest, France
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2
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Iorio L, Davanzo F, Cazzador D, Codirenzi M, Fiorin E, Zanatta E, Nicolai P, Doria A, Padoan R. Cocaine- and Levamisole-Induced Vasculitis: Defining the Spectrum of Autoimmune Manifestations. J Clin Med 2024; 13:5116. [PMID: 39274328 PMCID: PMC11396482 DOI: 10.3390/jcm13175116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Revised: 08/16/2024] [Accepted: 08/23/2024] [Indexed: 09/16/2024] Open
Abstract
Drug-induced or associated vasculitis is a prevalent form of vasculitis that resembles primary idiopathic antineutrophil cytoplasmic autoantibody (ANCA) vasculitis (AAV). Cocaine is a diffuse psychostimulant drug and levamisole is a synthetic compound used to cut cocaine. Their abuse may result in a spectrum of autoimmune manifestations which could be categorized into three overlapping clinical pictures: cocaine-induced midline destructive lesion (CIMDL), levamisole-adulterated cocaine (LAC) vasculopathy/vasculitis, and cocaine-induced vasculitis (CIV). The mechanisms by which cocaine use leads to disorders resembling AAV are not well understood. Cocaine can cause autoimmune manifestations ranging from localized nasal lesions to systemic diseases, with neutrophils playing a key role through NETosis and ANCA development, which exacerbates immune responses and tissue damage. Diagnosing and treating these conditions becomes challenging when cocaine and levamisole abuse is not suspected, due to the differences and overlaps in clinical, diagnostic, therapeutic, and prognostic aspects compared to primary idiopathic vasculitides.
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Affiliation(s)
- Luca Iorio
- Rheumatology Unit, Department of Medicine DIMED, University of Padua, 35128 Padua, Italy
| | - Federica Davanzo
- Rheumatology Unit, Department of Medicine DIMED, University of Padua, 35128 Padua, Italy
| | - Diego Cazzador
- Otorhinolaryngology Section, Department of Neuroscience DNS, University of Padua, 35128 Padua, Italy
| | - Marta Codirenzi
- Rheumatology Unit, Department of Medicine DIMED, University of Padua, 35128 Padua, Italy
| | - Eleonora Fiorin
- Rheumatology Unit, Department of Medicine DIMED, University of Padua, 35128 Padua, Italy
| | - Elisabetta Zanatta
- Rheumatology Unit, Department of Medicine DIMED, University of Padua, 35128 Padua, Italy
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Piero Nicolai
- Otorhinolaryngology Section, Department of Neuroscience DNS, University of Padua, 35128 Padua, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine DIMED, University of Padua, 35128 Padua, Italy
| | - Roberto Padoan
- Rheumatology Unit, Department of Medicine DIMED, University of Padua, 35128 Padua, Italy
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3
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Antohi DR, Lei D, Occidental M, Amin B, Lee J, Wang S, Wu B. Violaceous nodules of the extensor joints - a clinicopathological challenge. Int J Dermatol 2024. [PMID: 39188029 DOI: 10.1111/ijd.17447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 07/21/2024] [Accepted: 08/06/2024] [Indexed: 08/28/2024]
Abstract
Antineutrophilic cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a condition characterized by vessel inflammation and may have a variety of etiologies. Among these, cocaine and its common adulterant, levamisole, have been described to contribute to the development of AAV with distinct cutaneous manifestations. Classically, these manifestations involve purpuric or necrotic lesions involving the ears, nose, and extremities. However, we present a case of cocaine-induced AAV presenting with violaceous nodules on the dorsal hands in order to demonstrate that this condition may not always present with retiform purpura and skin necrosis.
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Affiliation(s)
- Daniel R Antohi
- Division of Dermatology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Donald Lei
- Division of Dermatology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Michael Occidental
- Department of Pathology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Bijal Amin
- Division of Dermatology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Pathology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jeanie Lee
- Department of Rheumatology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Shudan Wang
- Department of Rheumatology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Benedict Wu
- Division of Dermatology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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4
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Aqeel F, Geetha D. Kidney Failure in Pauci-immune Crescentic Glomerulonephritis: Rationale for Immunosuppression to Improve Kidney Outcome. Curr Rheumatol Rep 2024; 26:290-301. [PMID: 38709420 DOI: 10.1007/s11926-024-01150-z] [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] [Accepted: 04/26/2024] [Indexed: 05/07/2024]
Abstract
PURPOSE OF REVIEW Pauci-immune crescentic glomerulonephritis is the hallmark finding in ANCA-associated vasculitis (AAV) when the kidneys are affected. The rationale for immunosuppression in AAV is based on the underlying autoimmune nature of the disease. Overall remission rates, kidney outcomes, and the burden of disease have greatly improved since the discovery of various immunosuppressive therapies, but relapses remain common, and a significant proportion of patients continue to progress to end-stage kidney disease. Here, we review the role of immunosuppressive therapies for the treatment of pauci-immune crescentic glomerulonephritis. RECENT FINDINGS Besides the recognized role of B and T cells in the pathogenies of AAV, the focus on the contribution of inflammatory cytokines, neutrophil extracellular traps (NETs), and the complement system allowed the discovery of new therapies. Specifically, the C5a receptor blocker (avacopan) has been approved as a glucocorticoid-sparing agent. Additionally, based on observational data, more clinicians are now using combination therapies during the induction phase. There is also an evolving understanding of the role of plasma exchange in removing ANCA antibodies. Furthermore, the recent development of risk score systems provides physicians with valuable prognostic information that can influence decisions on immunosuppression, although future validation from larger cohorts is needed. The over-activation of various immune pathways plays a significant role in the pathogenesis of pauci-immune crescentic glomerulonephritis in AAV. Immunosuppression is, therefore, an important strategy to halt disease progression and improve overall outcomes. Relapse prevention while minimizing adverse events of immunosuppression is a major long-term goal in AAV management.
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Affiliation(s)
- Faten Aqeel
- Department of Internal Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, 301 Mason Lord Drive, Baltimore, MD, USA
| | - Duvuru Geetha
- Department of Internal Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, 301 Mason Lord Drive, Baltimore, MD, USA.
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5
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Sinha R, Sarkar S, Banerjee S, Akhtar S, Poddar S, Dasgupta D, Saha R, Sengupta J, Mandal M, Tse Y, Pahari A. Antineutrophil cytoplasmic antibody in children with nephrotic syndrome treated with levamisole: a cross-sectional cohort study. Pediatr Nephrol 2024; 39:2423-2427. [PMID: 38589697 DOI: 10.1007/s00467-024-06362-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 03/10/2024] [Accepted: 03/11/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Levamisole is a commonly used steroid-sparing agent (SSA), but the reported incidence of antineutrophil cytoplasmic antibody (ANCA) positivity has been concerning. METHODS Observational cross-sectional study wherein children aged 2 to 18 years with frequently relapsing/steroid dependent nephrotic syndrome (FRNS/SDNS) on levamisole for ≥ 12 months were tested for ANCA. RESULTS A total of 210 children (33% female), median age of 7.3 (IQR: 5.6-9.6) years, and a median duration of levamisole exposure of 21 (IQR: 15-30) months were tested. ANCA was positive in 18% (n = 37): 89% (n = 33) perinuclear ANCA (pANCA), 3% (n = 1) cytoplasmic ANCA (cANCA), and 8% (n = 3) both. Of ANCA-positive children, none had reduced eGFR or abnormal urinalysis. The majority of these children were asymptomatic (81%, n = 30). Rash was more common among ANCA-positive children [6/37 (16%) vs. 3/173 (2%), p = 0.0001]. On multivariate analysis, higher age (OR = 1.02, [95th CI: 1.01 to 1.03], p = 0.007) and longer duration of levamisole exposure (OR = 1.05, [95th CI: 1.02 to 1.08], p = 0.0007) were associated with ANCA positivity. Levamisole was stopped in ANCA-positive children with the resolution of any clinical manifestations if present. Repeat ANCA testing was performed in 54% (20/37), and all were ANCA negative by 18 months. CONCLUSIONS Children with FRNS/SDNS on longer duration of levamisole were associated with increasing prevalence of ANCA positivity, but most of these children were clinically asymptomatic. Prospective studies are required to determine the chronology of ANCA positivity and its clinical implication.
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Affiliation(s)
- Rajiv Sinha
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 700019, India.
| | | | - Sushmita Banerjee
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 700019, India
| | - Shakil Akhtar
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 700019, India
| | - Sanjukta Poddar
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 700019, India
| | - Deblina Dasgupta
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 700019, India
| | - Rana Saha
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 700019, India
| | - Jayati Sengupta
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 700019, India
| | - Mita Mandal
- All India Institute of Medical Sciences, Kalyani, India
| | - Yincent Tse
- Great North Children's Hospital, Newcastle Upon Tyne, UK
| | - Amitava Pahari
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 700019, India
- Apollo Multispecialty Hospital, Kolkata, India
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Major T, Nagy G, Szabó J, Mózes H, Szűcs G, Szekanecz Z, Szamosi S. Granulomatosis with polyangiitis or its mimic? A case report. J Int Med Res 2024; 52:3000605241237876. [PMID: 38606757 PMCID: PMC11015776 DOI: 10.1177/03000605241237876] [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: 10/31/2023] [Accepted: 02/21/2024] [Indexed: 04/13/2024] Open
Abstract
Differentiation between granulomatosis with polyangiitis (GPA) limited to the upper airways and cocaine-induced midline destructive lesion (CIMDL) may be particularly difficult because of their common histopathologic features and antineutrophil cytoplasmic antibody (ANCA) profiles. We herein present a case involving a young woman with an initial diagnosis of GPA based on upper and lower airway manifestations and constitutional symptoms, histopathologic evidence of granulomas, a positive cytoplasmic ANCA indirect immunofluorescent test result, and proteinase 3 positivity by enzyme-linked immunosorbent assay (ELISA). CIMDL was confirmed based on the appearance of a hard palate perforation, positivity for methylecgonine on urine toxicology, a positive perinuclear ANCA indirect immunofluorescent test result, and subsequent human neutrophil elastase (HNE) ANCA positivity by ELISA. Finally, based on the coexistence of CIMDL, constitutional symptoms, and lower airway manifestations, the diagnosis was modified to cocaine-induced GPA mimic. Urine toxicology for cocaine and HNE ELISA are indicated in young patients with GPA who develop limited airway disease to check for the presence of CIMDL and cocaine-/levamisole-induced ANCA-associated vasculitis. Continued abstinence from cocaine is the first-choice therapy for both CIMDL and cocaine-induced GPA mimic.
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Affiliation(s)
- Tamás Major
- Department of Otorhinolaryngology, Heves County Markhot Ferenc Teaching Hospital and Outpatient Clinic, Eger, Hungary
| | - Gábor Nagy
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Judit Szabó
- Department of Pathology, Péterfy Sándor Street Hospital-Policlinic, Budapest, Hungary
| | - Huba Mózes
- Ear-Nose-Throat Department, Emergency County Hospital, Oradea, Romania
| | - Gabriella Szűcs
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Szekanecz
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Szilvia Szamosi
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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7
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Charn G, Sturman J, Ozbek L, Henderson S, Burns A, Hamour S, Pepper R, McClelland L, Chanouzas D, Gane S, Salama A, Harper L. Cocaine-induced granulomatosis with polyangiitis: an under-recognised condition. Clin Med (Lond) 2023; 23:23. [PMID: 38182208 PMCID: PMC11046595 DOI: 10.7861/clinmed.23-6-s23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024]
Affiliation(s)
- Gill Charn
- University Hospitals Birmingham NHS Foundation Trust
| | | | - Leyla Ozbek
- University College London Hospitals NHS Foundation Trust
| | | | - Aine Burns
- University College London Hospitals NHS Foundation Trust
| | - Sally Hamour
- University College London Hospitals NHS Foundation Trust
| | - Ruth Pepper
- University College London Hospitals NHS Foundation Trust
| | | | | | - Simon Gane
- University College London Hospitals NHS Foundation Trust
| | - Alan Salama
- University College London Hospitals NHS Foundation Trust
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8
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Escolà-Rodríguez A, Parra-Robert M, Carrasco-Gómez D, Escartín-Díez T, Fabregat-Bolufer AB. Diagnosis of cocaine-induced midline destructive lesions. Clin Toxicol (Phila) 2023; 61:709-710. [PMID: 37754320 DOI: 10.1080/15563650.2023.2259090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 09/09/2023] [Indexed: 09/28/2023]
Affiliation(s)
- Alba Escolà-Rodríguez
- Pharmacy Service, Division of Medicines, Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Marina Parra-Robert
- Pharmacology and Toxicology Laboratory, Service of Biochemistry and Molecular Genetics, Biomedical Diagnostic Center (CDB), Hospital Clínic of Barcelona, Barcelona, Spain
| | | | | | - Aleix B Fabregat-Bolufer
- CORE Laboratory, Service of Biochemistry and Molecular Genetics, Biomedical Diagnostic Center (CDB), Hospital Clínic of Barcelona, Barcelona, Spain
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9
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Shoji MK, Staropoli P, Tran AQ, Thaller S, Kirsner RS, Dubovy SR, Blessing NW, Alabiad CR. Periorbital Pyoderma Gangrenosum Associated With a Cocaine-Induced Midline Destructive Lesion: Case Report and Review of the Literature. Ophthalmic Plast Reconstr Surg 2023; 39:e91-e96. [PMID: 36893063 PMCID: PMC10175135 DOI: 10.1097/iop.0000000000002347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
A 72-year-old woman with a history of chronic cocaine use presented 9 months after a dog bite with a large facial ulceration and absent sinonasal structures. Biopsies were negative for infectious, vasculitic, or neoplastic pathologies. The patient was lost to follow up for 15 months and returned with a significantly larger lesion despite abstinence from cocaine. Additional inflammatory and infectious workup was negative. Intravenous steroids were administered with clinical improvement. Therefore, she was diagnosed with pyoderma gangrenosum and cocaine-induced midline destructive lesion due to cocaine/levamisole. Pyoderma gangrenosum is a rare dermatologic condition that uncommonly involves the eye and ocular adnexa. Diagnosis involves clinical examination, response to steroids, exclusion of infectious or autoimmune conditions, and identifying potential triggers including cocaine/levamisole. This report highlights a rare presentation of periorbital pyoderma gangrenosum causing cicatricial ectropion associated with concomitant cocaine-induced midline destructive lesion and reviews important aspects of clinical manifestations, diagnosis, and management of pyoderma gangrenosum and cocaine/levamisole autoimmune phenomenon.
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Affiliation(s)
- Marissa K. Shoji
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miami, FL
| | - Patrick Staropoli
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miami, FL
| | - Ann Q. Tran
- Department of Ophthalmology, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL
| | - Seth Thaller
- Department of Plastic Surgery, University of Miami, Miami, FL
| | - Robert S. Kirsner
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami, Miami, FL
| | - Sander R. Dubovy
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miami, FL
| | - Nathan W. Blessing
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miami, FL
| | - Chris R. Alabiad
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miami, FL
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10
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McEneaney PA, Nicklas BJ, Kuba JL, Rundell JD. Cutaneous Pedal Manifestations in Patient With Hepatitis C Virus-Associated Cryoglobulinemia: Case Report and Review of Literature. THE INTERNATIONAL JOURNAL OF LOWER EXTREMITY WOUNDS 2023; 22:126-129. [PMID: 33089718 DOI: 10.1177/1534734620961893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
| | - Bonnie J Nicklas
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA
| | - Jennifer L Kuba
- Department of Veterans Affair Medical Center, Cleveland, OH, USA
| | - Joseph D Rundell
- Northern Illinois Foot and Ankle Specialists, Crystal Lake, IL, USA
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11
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Jaenke CM, Moore SR, Miller MD, Garg A. A Case of Cutaneous Vasculitis in the Setting of Systemic Lupus Erythematosus and Cocaine Use. J Investig Med High Impact Case Rep 2023; 11:23247096231176215. [PMID: 37209041 DOI: 10.1177/23247096231176215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023] Open
Abstract
Cocaine, one of most prevalent illicit substances in the United States, affects a multitude of organ systems and precedes numerous negative health outcomes. Many of the consequences of cocaine are linked to induction of vasoconstriction. For this reason, cocaine users are placed at considerable risk of ischemic stroke, myocardial infarction, and cardiac arrhythmias. Furthermore, a prominent contaminant, levamisole, has been widely implicated in predisposing individuals to developing or exacerbating cutaneous vasculitides. This report details a 31-year-old woman with acute, localized necrotic skin lesions after cocaine use. Her clinical picture was complicated by a 17-year history of systemic lupus erythematosus (SLE) and Raynaud's phenomenon. This case examines the challenge of forming a differential diagnosis, initiating an appropriate workup, and interpreting serologic-based and immunologic-based studies to differentiate between SLE and drug-based etiologies of skin necrosis. Finally, we discuss appropriate treatment plans to mitigate symptoms and reduce future instances of drug-induced vasculitis.
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Affiliation(s)
| | - Sara R Moore
- The University of Toledo Medical Center, OH, USA
| | | | - Anu Garg
- The University of Toledo Medical Center, OH, USA
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12
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Lim JHL, Lee JSS. Acute iododerma presenting as cryptococcoid neutrophilic dermatosis: A clinicopathological pitfall and interesting findings gleaned from a review of the literature. J Cutan Pathol 2023; 50:29-34. [PMID: 35950337 DOI: 10.1111/cup.14310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/31/2022] [Accepted: 08/03/2022] [Indexed: 01/03/2023]
Abstract
Iododerma is an uncommon dermatosis caused by excessive iodine exposure and is associated with significant morbidity and mortality. Because of its heterogenous clinical presentation and variable histopathological findings, which depend on the time the skin biopsy is performed, the diagnosis of iododerma is often delayed. We report a rare case of acute iododerma in a woman with end-stage diabetic nephropathy with antecedent radioiodine contrast exposure, presenting histopathologically as cryptococcoid neutrophilic dermatosis (CND). We underscore important clinicopathological pitfalls to avoid misdiagnosis with similar overlapping entities such as Sweet syndrome, review all published cases of CND and draw novel insights into its associated entities.
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13
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Keim CK, Schwartz RA, Kapila R. Levamisole-induced and COVID-19-induced retiform purpura: two overlapping, emerging clinical syndromes. Arch Dermatol Res 2023; 315:265-273. [PMID: 34807290 PMCID: PMC8607060 DOI: 10.1007/s00403-021-02303-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 11/11/2021] [Indexed: 10/28/2022]
Abstract
Levamisole exposure in cocaine users is a well-recognized cause of retiform purpura, a distinctive net-like maculopapular patch. Prolonged exposure to levamisole can lead to a serious systemic syndrome known as levamisole-induced vasculitis, most commonly involving the kidneys and lungs. More recently, retiform purpura has been observed in patients with the novel coronavirus disease of 2019 (COVID-19). Due to their overlapping dermatologic and systemic manifestations, levamisole-induced and COVID-19-induced retiform purpura may mimic one another in clinical presentation. The possibility that patients may present with one or both syndromes creates a diagnostic challenge. This review of levamisole-induced and COVID-19-induced retiform purpura highlights their corresponding and distinctive features. Additionally, we propose a unique staging system for levamisole-induced retiform purpura that may be valid for future classification of COVID-19-induced retiform purpura.
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Affiliation(s)
- Catherine K. Keim
- grid.430387.b0000 0004 1936 8796Rutgers New Jersey Medical School, MSB H-576, 185 South Orange Ave, Newark, NJ 07103 USA
| | - Robert A. Schwartz
- grid.430387.b0000 0004 1936 8796Dermatology and Pathology, Rutgers New Jersey Medical School, MSB H-576, 185 South Orange Ave, Newark, NJ 07103 USA
| | - Rajendra Kapila
- grid.430387.b0000 0004 1936 8796Infectious Diseases, Rutgers New Jersey Medical School, MSB H-576, 185 South Orange Ave, Newark, NJ 07103 USA
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14
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Pulmonary Renal Syndrome: Perilous Presentation in Pediatrics. Indian Pediatr 2022. [PMCID: PMC9748884 DOI: 10.1007/s13312-022-2652-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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15
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Zhao WM, Wang ZJ, Shi R, Zhu YY, Zhang S, Wang RF, Wang DG. Environmental factors influencing the risk of ANCA-associated vasculitis. Front Immunol 2022; 13:991256. [PMID: 36119110 PMCID: PMC9479327 DOI: 10.3389/fimmu.2022.991256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 08/19/2022] [Indexed: 11/13/2022] Open
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a group of diseases characterized by inflammation and destruction of small and medium-sized blood vessels. Clinical disease phenotypes include microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA), and eosinophilic granulomatosis with polyangiitis (EGPA). The incidence of AAV has been on the rise in recent years with advances in ANCA testing. The etiology and pathogenesis of AAV are multifactorial and influenced by both genetic and environmental factors, as well as innate and adaptive immune system responses. Multiple case reports have shown that sustained exposure to silica in an occupational environment resulted in a significantly increased risk of ANCA positivity. A meta-analysis involving six case-control studies showed that silica exposure was positively associated with AAV incidence. Additionally, exposure to air pollutants, such as carbon monoxide (CO), is a risk factor for AAV. AAV has seasonal trends. Studies have shown that various environmental factors stimulate the body to activate neutrophils and expose their own antigens, resulting in the release of proteases and neutrophil extracellular traps, which damage vascular endothelial cells. Additionally, the activation of complement replacement pathways may exacerbate vascular inflammation. However, the role of environmental factors in the etiology of AAV remains unclear and has received little attention. In this review, we summarized the recent literature on the study of environmental factors, such as seasons, air pollution, latitude, silica, and microbial infection, in AAV with the aim of exploring the relationship between environmental factors and AAV and possible mechanisms of action to provide a scientific basis for the prevention and treatment of AAV.
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16
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Austin K, Janagan S, Wells M, Crawshaw H, McAdoo S, Robson JC. ANCA Associated Vasculitis Subtypes: Recent Insights and Future Perspectives. J Inflamm Res 2022; 15:2567-2582. [PMID: 35479831 PMCID: PMC9037725 DOI: 10.2147/jir.s284768] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 03/04/2022] [Indexed: 12/19/2022] Open
Abstract
The ANCA associated vasculitides (AAVs) affect a range of internal organs including ear nose and throat, respiratory tract, kidneys, skin and nervous system. They include granulomatosis with polyangiitis (GPA), eosinophilic granulomatosis with polyangiitis (EGPA) and microscopic polyangiitis (MPA). The AAVs are treated with high dose glucocorticoids, immunosuppressants, and targeted biological medications. Since the 1990s classification criteria for the AAVs have been based on clinical features, laboratory tests and basic imaging; an initiative to update the classification criteria incorporating newer tests, for example, anti-neutrophil cytoplasmic antibodies (ANCA) and novel imaging techniques will be published this year. There is also evidence for classification of patients based on ANCA subtype; those with anti-proteinase 3 antibodies (PR3) or anti-myeloperoxidase antibodies (MPO) have differences in response to treatment and clinical outcomes. An update is described within this review. The pathogenesis of AAV involves necrotizing inflammation of small to medium blood vessels involving multiple immunological pathways. We present an update on emerging evidence related to auto-antibodies, complement and lymphocyte pathways. This review describes emerging treatment regimens, including evidence for plasma exchange in severe disease and the inhibitor of the complement C5a receptor (C5aR) inhibitor, Avacopan. Lastly, patient reported outcomes are key secondary outcomes in randomised controlled trials and increasingly clinical practice, we report development in disease specific and glucocorticoid-specific PROs.
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Affiliation(s)
- Keziah Austin
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Bath, UK
| | - Shalini Janagan
- Department of Rheumatology, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Matthew Wells
- Department of Rheumatology, North Bristol NHS Trust, Bristol, UK
| | - Helena Crawshaw
- Department of Rheumatology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Stephen McAdoo
- Department of Medicine, Imperial College London, London, UK
| | - Joanna C Robson
- Department of Rheumatology, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
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17
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Shah NR, Tavana S, Opoku A, Martin D. Toxic and metabolic leukoencephalopathies in emergency department patients: a primer for the radiologist. Emerg Radiol 2022; 29:545-555. [PMID: 35201508 DOI: 10.1007/s10140-022-02032-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 02/14/2022] [Indexed: 10/19/2022]
Abstract
One of the most common chief complaints in the emergency department (ED) is altered mental status (AMS). Imaging plays a critical role in triaging patients and identifying the etiology of AMS. Toxic and metabolic etiologies are one of the primary differential categories for AMS, leading to toxic leukoencephalopathies. Toxic leukoencephalopathies are white matter disorders that result from either exogenous or endogenous sources. Common exogeneous causes of toxic leukoencephalopathy include drugs of abuse (heroin and cocaine), alcohol, inhaled gases (carbon monoxide), industrial agents (pesticides, toluene, ethylene glycol), and neurotoxic medications (methotrexate, metronidazole, vigabatrine, etc.); endogenous causes include hyper- and hypoglycemia, hyperammonemia, hyponatremia, and uremia. The imaging findings of toxic leukoencephalopathies manifest through a combination of vasogenic and cytotoxic edema, resulting in white matter patterns. These white matter patterns have been found to be pathognomonic. In the ED setting, it is imperative to develop a diagnosis based off of the imaging due to the lack of history and context that is typically provided with a chief complaint of altered mental status (AMS). To offer expeditious and accurate diagnosis, we present the classic imaging features of toxic leukoencephalopathies and correlate these imaging findings with pathophysiology.
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Affiliation(s)
- Neal R Shah
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH, 44106, USA.
| | - Shahrzad Tavana
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH, 44106, USA
| | - Akwasi Opoku
- Department of Radiology, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN, 37232, USA
| | - Douglas Martin
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH, 44106, USA
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18
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Abstract
Early identification of cutaneous manifestations of alcohol and illicit drug use can aid in the diagnosis and management of these uses, as well as their sequelae. In addition, the effects of alcohol and illicit drug use on the skin can result in significant morbidity. Alcohol misuse can present with jaundice, pruritus, pigmentary alterations, urticaria, hair and nail changes, and oral changes. It is also a risk factor for skin cancer and infections. Vascular disturbances associated with alcohol misuse include telangiectasias, palmar erythema, caput medusae, and flushing. Diseases related to alcohol misuse include nutritional deficiencies, porphyria cutanea tarda, psoriasis, seborrheic dermatitis, nummular dermatitis, and rosacea. Other conditions seen in alcohol misuse include Dupuytren contracture, Peyronie disease, and pancreatitis. Dermatologists should also be aware of hepatotoxic medications that are commonly prescribed for skin diseases so as to avoid initiating hepatoxicity in patients who use alcohol. Illicit drug use can manifest with cutaneous fibrosis, scarring, granulomas, ulceration, pruritus, infections, cocaine-levamisole-induced vasculitis, tooth decay, and oral disease. By recognizing the cutaneous stigmata of alcohol and illicit drug use, dermatologists can aid in the identification and treatment of patients suffering from these addictions.
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Affiliation(s)
- Neelesh P Jain
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Kimberly Shao
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Campbell Stewart
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Jane M Grant-Kels
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut, USA.
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19
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Gill H, Trinh D, Anderson DJ, Li N, Madenberg D. Cocaine and Levamisole Induced Vasculitis. Cureus 2021; 13:e17192. [PMID: 34548986 PMCID: PMC8439268 DOI: 10.7759/cureus.17192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2021] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Harpreet Gill
- Hospital Medicine, Medical College of Wisconsin, Wauwatosa, USA
| | - Dylan Trinh
- School of Medicine, Medical College of Wisconsin, Wauwatosa, USA
| | | | - Nathan Li
- School of Medicine, Medical College of Wisconsin, Wauwatosa, USA
| | - Devin Madenberg
- Internal Medicine, Medical College of Wisconsin, Wauwatosa, USA
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20
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Krischock L, Pannila P, Kennedy SE. Levamisole and ANCA positivity in childhood nephrotic syndrome. Pediatr Nephrol 2021; 36:1795-1802. [PMID: 33484340 DOI: 10.1007/s00467-020-04915-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/03/2020] [Accepted: 12/31/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study aimed to determine the prevalence of ANCA positivity in children managed with levamisole as a steroid-sparing agent for nephrotic syndrome (NS). METHODS Medical records of children with steroid-sensitive NS managed with levamisole therapy at Sydney Children's Hospital between 1/1/2000 and 31/12/2018 were retrospectively reviewed. Main outcome measure was side effects of levamisole therapy including ANCA positivity. RESULTS Seventy-one children, median age 3 years and 1 month (IQR 29-68 months) at first presentation, were subsequently managed with levamisole. 60.6% were male and 65% Caucasian. 47.9% had frequently relapsing (FR)NS and 52.1% steroid-dependent (SD)NS. Overall, there was a median reduction in relapses from 3 (IQR 1-5) to 0.4 relapses (IQR 0-1) per year after levamisole was commenced. Levamisole was successful in preventing relapse in 19 (29%) patients and was used for median 24 (22 to 25) months. Levamisole was discontinued due to relapse in 25 patients (38%) after median 12 (5-28) months. Side effects occurred in 28 patients (42.4%); the most common side effect was ANCA positivity in 12 patients. In eleven of these patients, levamisole was discontinued; in one patient, low-level titres were documented and spontaneously resolved without cessation of levamisole. Two patients developed ANCA-associated vasculitis. CONCLUSION ANCA positivity is a common side effect of levamisole and was seen in 18.2% of our patients. Monitoring is required to determine side effects including ANCA positivity and treatment modified accordingly.
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Affiliation(s)
- Leah Krischock
- Department of Nephrology, Sydney Children's Hospital, Randwick, NSW, Australia. .,School of Women's and Children's Health, UNSW Medicine, University of New South Wales, Sydney, NSW, Australia.
| | - Pasan Pannila
- School of Women's and Children's Health, UNSW Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Sean E Kennedy
- Department of Nephrology, Sydney Children's Hospital, Randwick, NSW, Australia.,School of Women's and Children's Health, UNSW Medicine, University of New South Wales, Sydney, NSW, Australia
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21
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Al-Khafaji M, Podbicanin S, Ghaghda D, Basi S, Punekar S. Simultaneous multifocal intracranial haemorrhage (ICH) and subarachnoid haemorrhage (SAH) in the setting of long-term cocaine usage. BMJ Case Rep 2021; 14:14/6/e241311. [PMID: 34140326 DOI: 10.1136/bcr-2020-241311] [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] [Indexed: 11/03/2022] Open
Abstract
A 45-year-old Caucasian man was admitted to hospital following a collapse at home. On admission, this patient was noted to have a Glasgow Coma Scale (GCS) Score of 9 out of 15, fever and tachypnoea. The patient was identified to have bilateral limb weakness, predominately on the left side, with associated dysphagia. Radiological imaging demonstrated bilateral multifocal intracranial haemorrhage and subarachnoid haemorrhage. Neurosurgical input was sought; the outcome of this was a decision to manage the patient conservatively, without surgical intervention. Of note, his urine drug testing revealed a positive result for a cocktail of drugs including cocaine, benzoylecgonine (cocaine metabolite), methadone, heroin, norbuprenorphine and benzodiazepine. Throughout the admission, the patient was monitored in an intensive care setting. The patient received support with feeding, speech and mobilisation. The patients' GCS improved throughout the admission. Following a 30-day admission, the patient walked home.
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Affiliation(s)
| | | | - Deep Ghaghda
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Saajan Basi
- General Internal Medicine, Royal Derby Hospital, Derby, UK
- Acute Stroke Department, King's Mill Hospital, Sutton-in-Ashfield, UK
| | - Shuja Punekar
- Sherwood Forest Hospitals NHS Trust, Nottinghamshire, UK
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22
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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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23
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Vermeulen L, Dirix M, Dendooven A. Cocaine Consumption and Antineutrophil Cytoplasmic Antibody-associated Glomerulonephritis: A Case Report. Am J Forensic Med Pathol 2021; 42:198-200. [PMID: 33186130 DOI: 10.1097/paf.0000000000000618] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Cocaine is often sold in a mixture with levamisole to increase the profit margin and potentiate the euphoric effect. Apart from an overdose, cocaine can induce a wide range of clinical symptoms. We present a case of cocaine/levamisole-induced pauci-immune glomerulonephritis. A 22-year-old patient was sent to the hospital after a laboratory result showed an unexpected acute kidney injury, with an estimated glomerular filtration rate of 34 mL/min/1.73 m2. The medical history included cocaine abuse. Renal biopsy showed a pauci-immune necrotizing glomerulonephritis. Antineutrophil cytoplasmic antibodies were positive with a perinuclear staining pattern and target specificity for leucocyte myeloperoxidase (antimyeloperoxidase). Despite treatment, the kidney function did not show significant improvement. The forensic implication of this case is that even if the toxicological values are not high enough to suggest a lethal intoxication, an idiosyncratic reaction on cocaine and/or levamisole has to be taken into account.
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24
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Sinha A, Bagga A, Banerjee S, Mishra K, Mehta A, Agarwal I, Uthup S, Saha A, Mishra OP. Steroid Sensitive Nephrotic Syndrome: Revised Guidelines. Indian Pediatr 2021; 58:461-481. [PMID: 33742610 PMCID: PMC8139225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
JUSTIFICATION Steroid sensitive nephrotic syndrome (SSNS) is one of the most common chronic kidney diseases in children. These guidelines update the existing Indian Society of Pediatric Nephrology recommendations on its management. OBJECTIVE To frame revised guidelines on diagnosis, evaluation, management and supportive care of patients with the illness. PROCESS The guidelines combine evidence-based recommendations and expert opinion. Formulation of key questions was followed by review of literature and evaluation of evidence by experts in two face-to-face meetings. RECOMMENDATIONS The initial statements provide advice for evaluation at onset and follow up and indications for kidney biopsy. Subsequent statements provide recommendations for management of the first episode of illness and of disease relapses. Recommendations on the use of immunosuppressive strategies in patients with frequent relapses and steroid dependence are accompanied by suggestions for step-wise approach and plan of monitoring. Guidance is also provided regarding the management of common complications including edema, hypovolemia and serious infections. Advice on immunization and transition of care is given. The revised guideline is intended to improve the management and outcomes of patients with SSNS, and provide directions for future research.
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Affiliation(s)
- Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India. Correspondence to: Dr. Arvind Bagga, Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
| | | | - Kirtisudha Mishra
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, Delhi, India
| | - Amarjeet Mehta
- Department of Pediatrics, Sawai Man Singh Medical College, Jaipur, India
| | - Indira Agarwal
- Department of Pediatrics, Christian Medical College, Vellore, India
| | - Susan Uthup
- Department of Pediatrics, Trivandrum Medical College, Thiruvananthapuram, India
| | - Abhijeet Saha
- Department of Pediatrics, Lady Hardinge Medical College, New Delhi, India
| | - Om Prakash Mishra
- Department of Pediatrics, Institute of Medical Sciences, Benaras Hindu University, Varanasi, India
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25
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Abousy M, Sylvester S, Milek D, Hultman CS, Caffrey J. Surgical management and outcomes of levamisole-induced vasculitis in a burn center: A case series. JAAD Case Rep 2021; 13:36-42. [PMID: 34136623 PMCID: PMC8182369 DOI: 10.1016/j.jdcr.2021.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Mya Abousy
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Scott Sylvester
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - David Milek
- Department of Surgery, University of Rochester School of Medicine, Rochester, New York
| | - C Scott Hultman
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Julie Caffrey
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
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26
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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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27
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Sinha A, Bagga A, Banerjee S, Mishra K, Mehta A, Agarwal I, Uthup S, Saha A, Mishra OP. Steroid Sensitive Nephrotic Syndrome: Revised Guidelines. Indian Pediatr 2021. [PMID: 33742610 PMCID: PMC8139225 DOI: 10.1007/s13312-021-2217-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Justification Steroid sensitive nephrotic syndrome (SSNS) is one of the most common chronic kidney diseases in children. These guidelines update the existing Indian Society of Pediatric Nephrology recommendations on its management. Objective To frame revised guidelines on diagnosis, evaluation, management and supportive care of patients with the illness. Process The guidelines combine evidence-based recommendations and expert opinion. Formulation of key questions was followed by review of literature and evaluation of evidence by experts in two face-to-face meetings. Recommendations The initial statements provide advice for evaluation at onset and follow up and indications for kidney biopsy. Subsequent statements provide recommendations for management of the first episode of illness and of disease relapses. Recommendations on the use of immunosuppressive strategies in patients with frequent relapses and steroid dependence are accompanied by suggestions for step-wise approach and plan of monitoring. Guidance is also provided regarding the management of common complications including edema, hypovolemia and serious infections. Advice on immunization and transition of care is given. The revised guideline is intended to improve the management and outcomes of patients with SSNS, and provide directions for future research.
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Affiliation(s)
- Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India. Correspondence to: Dr. Arvind Bagga, Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
| | | | - Kirtisudha Mishra
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, Delhi, India
| | - Amarjeet Mehta
- Department of Pediatrics, Sawai Man Singh Medical College, Jaipur, India
| | - Indira Agarwal
- Department of Pediatrics, Christian Medical College, Vellore, India
| | - Susan Uthup
- Department of Pediatrics, Trivandrum Medical College, Thiruvananthapuram, India
| | - Abhijeet Saha
- Department of Pediatrics, Lady Hardinge Medical College, New Delhi, India
| | - Om Prakash Mishra
- Department of Pediatrics, Institute of Medical Sciences, Benaras Hindu University, Varanasi, India
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28
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A Unique Presentation of Levamisole-Induced Antineutrophil- Cytoplasmic-Antibody-Positive Vasculitis Presenting as Inflammatory Orbitopathy. Ophthalmic Plast Reconstr Surg 2021; 36:e96-e100. [PMID: 32221103 DOI: 10.1097/iop.0000000000001612] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
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.
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29
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Pathogenesis and pathology of anti-neutrophil cytoplasmic antibody(ANCA)-associated vasculitis. J Transl Autoimmun 2021; 4:100094. [PMID: 33912820 PMCID: PMC8063861 DOI: 10.1016/j.jtauto.2021.100094] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 02/21/2021] [Accepted: 02/21/2021] [Indexed: 12/20/2022] Open
Abstract
AAV is characterized by necrotizing small vessel vasculitis with positive serum ANCA. MPO/PR3-ANCA and neutrophils play central roles in AAV pathogenicity. Dysregulated complement system primes neutrophils. MPO-ANCA directly activates neutrophils to induce NETosis followed by releasing NETs. B cells, T cells, and dendritic cells also contribute to the pathogenicity of AAV.
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30
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Phillips R, King M, McGilligan JA, Hajela V, Allan K. A retrospective review of four patients with severe nasal destruction secondary to cocaine adulterated with levamisole. Clin Otolaryngol 2021; 46:673-678. [PMID: 33386680 DOI: 10.1111/coa.13710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/24/2020] [Accepted: 12/20/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Rupert Phillips
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Matthew King
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | | | - Vijay Hajela
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Kimberley Allan
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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31
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Averchenkov D, Volik A, Fominykh V, Nazarov V, Moshnikova A, Lapin S, Brylev L, Guekht A. Acute disseminated encephalomyelitis. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:119-128. [DOI: 10.17116/jnevro2021121111119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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McBride JD, Elgart GW. Pyoderma gangrenosum-like facial ulcers in a woman associated with cocaine use and cANCA/anti-PR3 +, pANCA/anti-MPO - serology. JAAD Case Rep 2020; 6:945-950. [PMID: 32913885 PMCID: PMC7472800 DOI: 10.1016/j.jdcr.2020.07.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Jeffrey D McBride
- Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Florida.,Jackson Memorial Hospital, Miami, Florida
| | - George W Elgart
- Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Florida.,Jackson Memorial Hospital, Miami, Florida
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Guzman AK, Balagula Y. Drug-induced cutaneous vasculitis and anticoagulant-related cutaneous adverse reactions: insights in pathogenesis, clinical presentation, and treatment. Clin Dermatol 2020; 38:613-628. [PMID: 33341196 DOI: 10.1016/j.clindermatol.2020.06.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Drug-induced vasculitis and anticoagulant-related skin reactions are commonly encountered in the inpatient and outpatient settings. The spectrum of clinical presentation is broad and ranges from focal, skin-limited disease, to more extensive cutaneous and soft tissue necrosis, to potentially fatal systemic involvement. The prompt recognition of these adverse events can have a significant impact on patient morbidity and mortality. We highlight the key features of the clinical presentation with an emphasis on primary lesion morphology, distribution, and epidemiology of purpuric drug reactions. The proposed pathophysiology, histologic findings, and therapeutic interventions of these potentially life-threatening diseases are discussed.
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Affiliation(s)
- Anthony K Guzman
- Division of Dermatology, Department of Internal Medicine, Albert Einstein College of Medicine, Bronx, New York, USA.
| | - Yevgeniy Balagula
- Division of Dermatology, Department of Internal Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
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Segelmark M. Serological testing in small vessel vasculitis. Rheumatology (Oxford) 2020; 59:iii51-iii54. [PMID: 32348521 DOI: 10.1093/rheumatology/kez633] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/30/2019] [Indexed: 11/13/2022] Open
Abstract
Serological analysis has a central role in the diagnostic work-up of patients with suspected small vessel vasculitis, both for establishing a specific diagnosis and for the monitoring of response to therapy. Autoantibodies can be detected in all forms of primary small vessel vasculitis as well as in the most common forms of secondary vasculitis. For primary vasculitis the most important serological test is for ANCA. ANCA can be found in 75-95% of patients with pauci-immune small vessel vasculitis leading to this subgroup of vasculitides being named ANCA associated vasculitis. ANCA levels often follow this disease course, but the value of serial ANCA testing is controversial. Other important autoantibodies in primary small vessel vasculitis are anti-glomerular basement membrane antibodies, anti-C1q, anti-galactose deficient IgA and cryoglobulins. A wide variety of systemic inflammatory diseases and infections can be complicated by small vessel vasculitis and detected by serological testing. Important examples are SLE, rheumatoid arthritis, Hepatitis C and HIV.
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Affiliation(s)
- Mårten Segelmark
- Department of Clinical Sciences, Nephrology, Skane University Hospital, Lund University, Lund, Sweden
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Abstract
BACKGROUND Levamisole is an immunomodulatory medication previously used to treat rheumatoid arthritis and some types of cancers; it was banned for use in humans in 2000 owing to its harmful side effects. Use of levamisole-laced cocaine is associated with a life-threatening syndrome characterized by a necrotizing purpuric rash leading to tissue destruction and necrotic wounds. This Clinical Challenges article summarizes our experience with the care of 2 adult women diagnosed with levamisole-related vasculitis. CASE Case 1 is a 46-year-old woman who presented with joint pain in her hands and legs, along with bilateral ear pain, swelling, and bleeding. She was initially diagnosed with vasculitis and possible systemic lupus erythematosus. She experienced multiple recurrences and exacerbation of her condition over a period of months. She was ultimately diagnosed with levamisole-related vasculitis from recurrent cocaine use resulting in bilateral above the knee amputations. The second case is a 50-year-old woman who presented to our emergency department with redness and swelling of her bilateral lower extremities. She developed blisters and pustules that rapidly evolved into abscesses and red lesions over the course of several months. Her wounds also deteriorated despite topical therapy that occurred in a context of recurring use of cocaine. CONCLUSIONS Our experience with these cases suggests that WOC nurses should consider levamisole-induced vasculitis in all patients presenting with unexplained vasculitis-type lesions, and particularly when these lesions occur in the context of known or suspected use of illicit substances such as cocaine. Given the absence of clinical guidelines for this increasingly prevalent condition, we recommend wound care based on principles of moist wound healing, combined with judicious use of therapies with antimicrobial activity and nonadherent dressings to reduce pain. Finally, we strongly recommend that care of these patients occurs as one part of a multidisciplinary care approach that focuses on cessation of the use of cocaine and all other illicit substances.
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Allard-Chamard H, Liang P. Antineutrophil Cytoplasmic Antibodies Testing and Interpretation. Clin Lab Med 2019; 39:539-552. [PMID: 31668268 DOI: 10.1016/j.cll.2019.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The discovery of antineutrophil cytoplasmic antibodies (ANCA) helped establish ANCA-associated vasculitis as a separate and well-defined clinical entity. Its progressive incorporation into the clinical diagnosis algorithms has made ANCA testing a cornerstone immunoassay embedded in the management of ANCA-associated vasculitis. After its description by indirect immunofluorescence, proteinase-3 and myeloperoxidase were identified as principal ANCA targets. ANCA, and proteinase-3 and myeloperoxidase immunoassessment, have undergone iterative rounds of improvement in sensitivity and specificity. This article traces landmarks in the development of ANCA tests, describes common pitfalls arising during ANCA interpretation, and discusses new technologies to improve the future of ANCA testing.
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Affiliation(s)
- Hugues Allard-Chamard
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA; Division of Rheumatology, Faculty of Medicine and Health Sciences, Université de Sherbrooke; Centre de Recherche Clinique du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada; Division of Rheumatology, Centre intégré universitaire de santé et de service sociaux de l'Estrie - Centre hospitalier universitaire de Sherbrooke (CIUSSS de l'Estrie-CHUS), 3001, 12th Avenue North, Room 3853, Sherbrooke, Québec J1H 5N4, Canada.
| | - Patrick Liang
- Division of Rheumatology, Faculty of Medicine and Health Sciences, Université de Sherbrooke; Centre de Recherche Clinique du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada; Division of Rheumatology, Centre intégré universitaire de santé et de service sociaux de l'Estrie - Centre hospitalier universitaire de Sherbrooke (CIUSSS de l'Estrie-CHUS), 3001, 12th Avenue North, Room 3853, Sherbrooke, Québec J1H 5N4, Canada
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Segelmark M, Björck L. Streptococcal Enzymes as Precision Tools Against Pathogenic IgG Autoantibodies in Small Vessel Vasculitis. Front Immunol 2019; 10:2165. [PMID: 31616410 PMCID: PMC6763725 DOI: 10.3389/fimmu.2019.02165] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 08/28/2019] [Indexed: 11/24/2022] Open
Abstract
In primary systemic small vessel vasculitis autoantibodies are common and seem to play an important role in the pathogenesis. Autoantibodies in vasculitis are preferentially directed against components of the immune system or directly against components of the vessel wall. Plasmapheresis is often applied in emergency situationists when the function of vital organs is jeopardized, the level of clinical evidence to apply such therapy, however, varies between low and non-existing. Plasmapheresis is a blunt and unspecific instrument that requires several sessions to achieve a substantial reduction of autoantibody levels. IdeS and EndoS are two relatively recently discovered enzymes produced by S. pyogenes, that have a remarkable capacity to degrade and disarm IgG. They have shown positive results in several in vivo models of autoimmunity, and treatment with IdeS has successfully been used to inactivate HLA alloantibodies in patients undergoing renal transplantation. Both IdeS and EndoS have the potential to become precision tools to replace plasmapheresis in the treatment of vasculitic emergencies and a clinical trial of IdeS in anti-GBM vasculitis is now ongoing.
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Affiliation(s)
- Mårten Segelmark
- Nephrology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Lars Björck
- Infection Medicine, Department of Clinical Sciences, Lund University, Lund, Sweden
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