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Beato Merino M, Diago A, Fernandez-Flores A, Fraga J, García Herrera A, Garrido M, Idoate Gastearena M, Llamas-Velasco M, Monteagudo C, Onrubia J, Pérez-González Y, Pérez Muñoz N, Ríos-Martín J, Ríos-Viñuela E, Rodríguez Peralto J, Rozas Muñoz E, Sanmartín O, Santonja C, Santos-Briz A, Saus C, Suárez Peñaranda J, Velasco Benito V. Clinical and Histopathologic Characteristics of the Main Causes of Vascular Occusion — Part II: Coagulation Disorders, Emboli, and Other. ACTAS DERMO-SIFILIOGRAFICAS 2021. [DOI: 10.1016/j.adengl.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Beato Merino MJ, Diago A, Fernandez-Flores A, Fraga J, García Herrera A, Garrido M, Idoate Gastearena MA, Llamas-Velasco M, Monteagudo C, Onrubia J, Pérez-González YC, Pérez Muñoz N, Ríos-Martín JJ, Ríos-Viñuela E, Rodríguez Peralto JL, Rozas Muñoz E, Sanmartín O, Santonja C, Santos-Briz A, Saus C, Suárez Peñaranda JM, Velasco Benito V. Clinical and Histopathologic Characteristics of the Main Causes of Vascular Occusion - Part II: Coagulation Disorders, Emboli, and Other. ACTAS DERMO-SIFILIOGRAFICAS 2020; 112:103-117. [PMID: 33075291 DOI: 10.1016/j.ad.2020.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 10/08/2020] [Indexed: 12/15/2022] Open
Abstract
Vascular occlusion has multiple, diverse clinical manifestations, some of which can have grave consequences for patients. It also has a wide variety of causes, including thrombi, which we recently addressed in partI of this review. In this second part, we look at additional causes of vascular occlusion.
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Affiliation(s)
- M J Beato Merino
- Servicio de Anatomía Patológica, Hospital Universitario La Paz, Madrid, España
| | - A Diago
- Servicio de Dermatología, Hospital Universitario Miguel Servet, Zaragoza, España
| | - A Fernandez-Flores
- Servicio de Anatomía Patológica, Hospital Universitario El Bierzo, Ponferrada, León, España.
| | - J Fraga
- Servicio de Anatomía Patológica, Hospital Universitario de La Princesa, Madrid, España
| | - A García Herrera
- Servicio de Anatomía Patológica, Hospital Clínic, Barcelona, España
| | - M Garrido
- Servicio de Anatomía Patológica, Hospital Universitario 12 de Octubre, Madrid, España
| | - M A Idoate Gastearena
- Servicio de Anatomía Patológica, Hospital Universitario Virgen Macarena, Departamento de Citología, Histología y Anatomía Patológica, Facultad de Medicina, Universidad de Sevilla, Sevilla, España
| | - M Llamas-Velasco
- Servicio de Dermatología, Hospital Universitario de La Princesa, Madrid, España
| | - C Monteagudo
- Servicio de Anatomía Patológica, Hospital Clínico Universitario de Valencia, Facultad de Medicina, Universidad de Valencia, Valencia, España
| | - J Onrubia
- Servicio de Anatomía Patológica, Hospital Universitario San Juan de Alicante, Sant Joan d'Alacant, Alicante, España
| | | | - N Pérez Muñoz
- Servicio de Anatomía Patológica, Hospital Universitari General de Catalunya, Quirónsalud, Sant Cugat del Vallès, Barcelona, España
| | - J J Ríos-Martín
- Servicio de Anatomía Patológica, Hospital Universitario Virgen Macarena, Sevilla, España
| | - E Ríos-Viñuela
- Servicio de Dermatología, Fundación Instituto Valenciano de Oncología, Valencia, España
| | - J L Rodríguez Peralto
- Departamento de Anatomía Patológica, Hospital Universitario 12 de Octubre, Universidad Complutense, Instituto de Investigación I+12, Madrid, España
| | - E Rozas Muñoz
- Departamento de Dermatología, Hospital de San Pablo, Coquimbo, Chile
| | - O Sanmartín
- Servicio de Dermatología, Fundación Instituto Valenciano de Oncología, Valencia, España
| | - C Santonja
- Servicio de Anatomía Patológica, Fundación Jiménez Díaz, Madrid, España
| | - A Santos-Briz
- Servicio de Anatomía Patológica, Hospital Universitario de Salamanca, Salamanca, España
| | - C Saus
- Servicio de Anatomía Patológica, Hospital Universitario Son Espases, Palma de Mallorca, España
| | - J M Suárez Peñaranda
- Servicio de Anatomía Patológica, Hospital Clínico Universitario de Santiago, Santiago de Compostela, La Coruña, España
| | - V Velasco Benito
- Servicio de Anatomía Patológica, Hospital Universitario de Cruces, Barakaldo, Vizcaya, España
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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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Kunzler D, Lagrimas L, Vo T, DeCrescenzo A, Kaltwasser K, Wilson J. Antineutrophil cytoplasmic antibodies negative levamisole-induced leukocytoclastic vasculitis: a presumed case and literature review. Int J Dermatol 2018; 57:1411-1416. [DOI: 10.1111/ijd.14249] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 08/17/2018] [Accepted: 08/31/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Daniel Kunzler
- School of Medicine; University of Texas Medical Branch; Galveston TX USA
| | - Lauren Lagrimas
- School of Medicine; University of Texas Medical Branch; Galveston TX USA
| | - Thiennga Vo
- School of Medicine; University of Texas Medical Branch; Galveston TX USA
| | - Andrew DeCrescenzo
- Department of Internal Medicine; University of Texas Medical Branch; Galveston TX USA
| | - Kyle Kaltwasser
- Department of Dermatology; University of Texas Medical Branch; Galveston TX USA
| | - Janice Wilson
- Department of Dermatology; University of Texas Medical Branch; Galveston TX USA
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Antiphospholipid Syndrome: Multiple Manifestations in a Single Patient-A High Suspicion Is Still Needed. Case Rep Med 2017; 2017:5797041. [PMID: 28620416 PMCID: PMC5460429 DOI: 10.1155/2017/5797041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 04/12/2017] [Accepted: 05/04/2017] [Indexed: 11/23/2022] Open
Abstract
Antiphospholipid Syndrome (APS) is an autoimmune disorder with clinical and laboratory features of vascular thrombosis, pregnancy loss, and persistent antiphospholipid antibodies (aPLs). The pathophysiology is thought to involve the activation of endothelial cells, monocytes, platelets, and complement by aPLs. Disease can range from asymptomatic to rapidly fatal catastrophic APS. We present a case of a 34-year-old male referred for pancytopenia and splenomegaly. On examination, he had decreased sensation and 4/5 power in the left upper extremity. A lacy, purplish rash was noted on the trunk and upper extremity. MRI of brain showed acute/subacute lacunar infarctions. Laboratory studies revealed an elevated lactate dehydrogenase level, bilirubin and ferritin, decreased haptoglobin, and positive Coombs test. Antinuclear antibody test was negative and antiphospholipid antibody panel revealed positivity for anti-cardiolipin IgG and IgM, antiphosphatidylserine IgG, and anti-β2-glycoprotein IgG. The patient was diagnosed with primary APS. Pancytopenia is relatively rare in primary APS and is more often seen in secondary APS. Our patient demonstrated involvement of multiple organ systems as well as livedo reticularis and autoimmune-related findings such as Raynaud phenomenon and Coombs positive hemolytic anemia. We discuss the various clinical and laboratory findings in patients with APS that aid in diagnosis, as well as important management considerations.
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Cocaine-associated retiform purpura: a C5b-9-mediated microangiopathy syndrome associated with enhanced apoptosis and high levels of intercellular adhesion molecule-1 expression. Am J Dermatopathol 2014; 35:722-30. [PMID: 23392134 DOI: 10.1097/dad.0b013e31827eaf0b] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Cocaine-associated retiform purpura is a recently described entity characterized by striking hemorrhagic necrosis involving areas of skin associated with administration of cocaine. Levamisole, an adulterant in cocaine, has been suggested as the main culprit pathogenetically. Four cases of cocaine-associated retiform purpura were encountered in the dermatopathology practice of C. M. Magro. The light microscopic findings were correlated with immunohistochemical and immunofluorescence studies. All 4 cases showed a very striking thrombotic diathesis associated with intravascular macrophage accumulation. Necrotizing vasculitis was noted in 1 case. Striking intercellular adhesion molecule-1 (ICAM-1)/CD54 expression in vessel wall along with endothelial expression of caspase 3 and extensive vascular C5b-9 deposition was observed in all biopsies examined. Cocaine-induced retiform purpura is a C5b-9-mediated microvascular injury associated with enhanced apoptosis and prominent vascular expression of ICAM-1, all of which have been shown in prior in vitro and in vivo murine models to be a direct effect of cocaine metabolic products. Antineutrophilic cytoplasmic antibody and antiphospholipid antibodies are likely the direct sequelae of the proapoptotic microenvironment. The inflammatory vasculitic lesion could reflect the downstream end point reflective of enhanced ICAM-1 expression and the development of antineutrophilic cytoplasmic antibody. Levamisole likely works synergistically with cocaine in the propagation of this syndromic complex.
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Jiménez-Gallo D, Albarrán-Planelles C, Linares-Barrios M, García-Moreno E, de la Varga-Martínez R, Rodríguez-Hernández C. [Necrotizing vasculitis induced by cocaine]. Rev Clin Esp 2014; 214:e51-3. [PMID: 24625860 DOI: 10.1016/j.rce.2014.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Revised: 10/29/2013] [Accepted: 01/13/2014] [Indexed: 11/24/2022]
Affiliation(s)
- D Jiménez-Gallo
- Unidad de Gestión Clínica de Dermatología Médico-Quirúrgica y Venereología, Hospital Universitario Puerta del Mar, Cádiz, España.
| | - C Albarrán-Planelles
- Unidad de Gestión Clínica de Dermatología Médico-Quirúrgica y Venereología, Hospital Universitario Puerta del Mar, Cádiz, España
| | - M Linares-Barrios
- Unidad de Gestión Clínica de Dermatología Médico-Quirúrgica y Venereología, Hospital Universitario Puerta del Mar, Cádiz, España
| | - E García-Moreno
- Unidad de Gestión Clínica de Inmunología, Hospital Universitario Puerta del Mar, Cádiz, España
| | - R de la Varga-Martínez
- Unidad de Gestión Clínica de Inmunología, Hospital Universitario Puerta del Mar, Cádiz, España
| | - C Rodríguez-Hernández
- Unidad de Gestión Clínica de Inmunología, Hospital Universitario Puerta del Mar, Cádiz, España
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Pieralli F, Grazzini M, Vannucchi V, Mancini A, Cammelli D, Nozzoli C. Recurrent episodes of hemorrhagic alveolitis in relapsing catastrophic antiphospholipid syndrome: the same side of the dark moon. Clin Rheumatol 2013; 33:429-33. [PMID: 24362787 DOI: 10.1007/s10067-013-2454-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 10/28/2013] [Accepted: 11/27/2013] [Indexed: 11/30/2022]
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a rare variant of antiphospholipid syndrome characterized by widespread thrombotic microangiopathy and multiorgan failure. Clinically, CAPS signs and symptoms can mimic vasculitis of systemic lupus erythematosus, disseminated intravascular coagulation, and thrombotic thrombocytopenic purpura. CAPS is burdened by high mortality, nearly 50% in most series. However, patients surviving the acute phase rarely suffer of CAPS relapses. Moreover, concomitant pulmonary hemorrhagic alveolitis is a very rare complication warranting an ominous prognosis. Only few reports of relapsing CAPS are described in literature, and pathogenetic mechanisms are poorly understood and the optimal treatment is yet unknown. We report a case of a young man suffering from multiple relapses of CAPS and recurrent hemorrhagic pulmonary alveolitis refractory to aggressive combination treatment.
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Affiliation(s)
- Filippo Pieralli
- Internal and Emergency Medicine Unit, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy
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Gillis JA, Green P, Williams J. Levamisole-induced vasculopathy: staging and management. J Plast Reconstr Aesthet Surg 2013; 67:e29-31. [PMID: 23993750 DOI: 10.1016/j.bjps.2013.08.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 08/06/2013] [Accepted: 08/07/2013] [Indexed: 11/25/2022]
Affiliation(s)
- Joshua A Gillis
- Division of Plastic Surgery and Division of Dermatology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Peter Green
- Division of Plastic Surgery and Division of Dermatology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jason Williams
- Division of Plastic Surgery and Division of Dermatology, Dalhousie University, Halifax, Nova Scotia, Canada.
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Abstract
BACKGROUND Levamisole has recently been implicated as a cause of cutaneous vasculopathy in cocaine abusers. The objective of this study was to describe this relatively new entity by reviewing published cases identified through a literature search. METHODS Published reports identified through a search of PubMed database (from 1964 to November 2011) were reviewed to record clinical, serological and pathologic findings. RESULTS A cohort of 32 patients had a mean age of 44 ± 9 years with a female predominance (75%). Rash predominately affected lower extremities (87.5%), followed by face (78%) and ears (69%) and typically presented as purpuric plaques, which were seen in a retiform pattern in 16 (50%) and had central necrosis in 11 patients (34%). Leukopenia and neutropenia were found in 20 patients (63%). Antinuclear cytoplasmic antibody (ANCA) was positive in 30 patients (94%); p-ANCA in 28 patients (87.5%), c-ANCA in 19 (59%) and both in 17 patients (53%). Skin biopsy results were available for 29 patients: 14 (48%) had pure thrombotic vasculopathy, 4 (14%) had pure small vessel vasculitis and 11 (38%) had evidence of both. Treatment information was available for 30 patients. Only supportive care was given to 11 patients (37%), steroids to 16 (53%) and surgical treatment for 5 (17%). Clinical course of lesions was available for 24 patients. Rash resolved in 11 patients (46%) and improved in 13 (54%). During median follow-up of 21 days (range, 7-270 days), 10 of 22 patients had recurrences related to cocaine use. CONCLUSION Levamisole-induced cutaneous vasculopathy in cocaine users is characterized by a female predominance, a retiform purpuric rash with a predilection for lower extremities, autoantibody production, leukopenia and/or neutropenia and recurrences with future cocaine use.
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Magliocca KR, Coker NA, Parker SR. The head, neck, and systemic manifestations of levamisole-adulterated cocaine use. J Oral Maxillofac Surg 2013; 71:487-92. [PMID: 23298805 DOI: 10.1016/j.joms.2012.10.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 10/29/2012] [Indexed: 11/26/2022]
Abstract
Systemic complications of levamisole-adulterated cocaine (LAC) use have recently been described. The objective of this review is to increase awareness of these manifestations among oral and maxillofacial surgeons. LAC exposure through inhalation, nasal insufflation, or injection can induce cutaneous vasculopathy and hematologic abnormalities such as neutropenia or agranulocytosis. Unlike other vasculopathies involving the skin, LAC-induced vascular injury frequently manifests with purpuric and necrotic lesions that involve the face and ears. Oral manifestations have also been reported but are not yet well characterized. The aforementioned hematologic manifestations are not uncommon, and patients exposed to LAC are potentially at higher risk for infectious complications. When manifestations of LAC affect the head, neck, and oral cavity, oral and maxillofacial surgeons may be the first providers to encounter the patient. Early recognition of the clinical signs and laboratory abnormalities will better allow for distinguishing LAC-related effects from various clinical mimics, will facilitate appropriate patient management, and may further contribute to the understanding of the biological effects of LAC.
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Affiliation(s)
- Kelly R Magliocca
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA 30322, USA.
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Gulati S, Donato AA. Lupus anticoagulant and ANCA associated thrombotic vasculopathy due to cocaine contaminated with levamisole: a case report and review of the literature. J Thromb Thrombolysis 2012; 34:7-10. [PMID: 22437653 DOI: 10.1007/s11239-012-0711-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
A 2010 US report recently detected the presence of levamisole in greater than 77 % of seized cocaine samples. A syndrome of retiform purpura, often involving ears and flanks, with vasculopathy or vasculitis on biopsy, associated with anti-nuclear cytoplasmic antibodies as well as antiphospholipid antibodies, previously associated with therapeutic use of levamisole has now re-emerged, and is associated with cocaine adulterated with levamisole. Patients with this unusual constellation of signs and laboratory findings should be questioned about exposure to cocaine.
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Affiliation(s)
- Shuchi Gulati
- Department of Internal Medicine, The Reading Hospital and Medical Center, 6th Avenue and Spruce Street, West Reading, PA 19611, USA.
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Arora NP, Jain T, Bhanot R, Natesan SK. Levamisole-induced leukocytoclastic vasculitis and neutropenia in a patient with cocaine use: an extensive case with necrosis of skin, soft tissue, and cartilage. Addict Sci Clin Pract 2012. [PMID: 23186390 PMCID: PMC3509389 DOI: 10.1186/1940-0640-7-19] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Levamisole-induced vasculitis is a relatively new entity in people who use cocaine. We describe a 44-year-old woman with a history of cocaine use who presented with a complaint of a painful rash of 2-3 month’s duration on her extremities, cheeks, nose, and earlobes. She had not experienced fever, weight loss, alopecia, dry eyes, oral ulcers, photosensitivity, or arthralgia. Examination revealed tender purpuric eruptions with central necrosis on her nose, cheeks, earlobes, and extremities. Laboratory investigations revealed neutropenia, an elevated erythrocyte sedimentation rate (ESR), presence of lupus anticoagulant, low complement component 3 (C3), and presence of perinuclear anti-neutrophil cytoplasmic antibody (p-ANCA). A urine toxicology screen was positive for cocaine, and gas chromatography–mass spectrometry was positive for levamisole. Skin biopsy showed leukocytoclastic vasculitis and small vessel thrombosis. Necrotic lesions of the nose led to its self-amputation. Large bullae on the lower extremities ruptured, leading to wound infection and extensive necrosis that required multiple surgical debridements. When necrosis progressed despite debridement, bilateral above-knee amputation of the legs was performed. Once new lesions stopped appearing, the patient was discharged home. Two months later, she had a recurrence related to cocaine use. To the best of our knowledge, this is only the second reported case of levamisole-induced vasculitis that required above-knee amputation.
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Affiliation(s)
- Natasha Purai Arora
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit Medical Center, 4201 Saint Antoine Street, Detroit, 48201 MI, USA.
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Belfonte CD, Shanmugam VK, Kieffer N, Coker S, Boucree S, Kerr G. Levamisole-induced occlusive necrotising vasculitis in cocaine abusers: an unusual cause of skin necrosis and neutropenia. Int Wound J 2012; 10:590-6. [PMID: 22716045 DOI: 10.1111/j.1742-481x.2012.01027.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
We present three cases describing the various skin manifestations of presumed levamisole-contaminated cocaine use. Antibody-mediated vasculitis and neutropenia were consistent findings in these cases and repeat exposure resulted in distinct dermatologic complications. This phenomenon of levamisole-induced vasculitis and neutropenia is being increasingly described and has characteristic wound manifestations that must be recognised and treated early.
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Affiliation(s)
- Cassius D Belfonte
- Division of Cardiology, Howard University Hospital, Washington, DC, USA Division of Rheumatology, Immunology and Allergy, Georgetown University Hospital, Washington, DC, USA Division of Rheumatology, Veterans Affairs Hospital, Washington, DC, USA Department of Internal Medicine, Howard University Hospital, Washington, DC, USA
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Larocque A, Hoffman RS. Levamisole in cocaine: unexpected news from an old acquaintance. Clin Toxicol (Phila) 2012; 50:231-41. [PMID: 22455354 DOI: 10.3109/15563650.2012.665455] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Levamisole is a pharmaceutical with anthelminthic and immunomodulatory properties that was previously used in both animals and humans to treat inflammatory conditions and cancer. Levamisole has been identified as a cocaine adulterant in the United States since 2003. By 2009, the United States Drug Enforcement Administration (DEA) estimated that 69% of the cocaine seized contained levamisole. The first case reports of complications related to levamisole in cocaine users were published in 2009. The objectives of this article are to review the literature regarding the full spectrum of possible complications related to levamisole use for medical purposes, to review the current scope of levamisole-induced complications in cocaine users and to discuss the pharmacological properties that might explain the motivation behind the large-scale adulteration of cocaine with levamisole. Literature review revealed that significant complications were quickly reported when levamisole was used in inflammatory conditions. By 1976, several cases of leukopenia and agranulocytosis were reported. Recurrence with re-exposure was well described and agranulocytosis spontaneously reversed upon discontinuation of therapy. Vasculitis secondary to levamisole treatment was first reported in 1978 and mostly manifests as leukocytoclastic vasculitis, cutaneous necrotising vasculitis and thrombotic vasculopathy without vasculitis. These findings typically, but not invariably, involve the ear lobes. Discontinuation of levamisole therapy was again a critical part of the treatment. Various neurological side effects were described with levamisole therapy, the most concerning complication being multifocal inflammatory leukoencephalopathy (MIL). Literature review identified 203 unique cases of complications in cocaine users that can be attributed to levamisole adulteration. The two principal complications reported are haematological (140 cases of neutropenia) and dermatological (84 cases). Even though these complications can occur in isolation, many cases displayed both simultaneously. No formal case of leukoencephalopathy in the setting of cocaine use has been reported so far. A striking phenomenon is the apparent high level of recurrence (27.1%) of symptoms in cocaine users after re-exposure to cocaine that is presumably adulterated. The importance of accurately identifying levamisole-induced complications is therefore critical for symptomatic patients as discontinuation of exposure is fundamental and as a correct diagnosis prevents unnecessary and potentially dangerous use of other treatment modalities like powerful immunosuppressive therapy. Literature review suggests that levamisole might have the advantages of enhancing noradrenergic neurotransmission by inhibiting reuptake, by inhibiting MAO and/or COMT, by acting on ganglionic nicotinic receptors and by being partially metabolized into an amphetamine-like compound. It could also increase endogenous opioids and increase dopamine concentration in the cerebral reward pathway. These potential effects make levamisole an interesting choice as a cocaine adulterant. It seems unlikely that levamisole use as a cocaine adulterant will soon reach an end. More information is needed about the diagnosis and treatment of levamisole-induced complications, and the efforts of the medical and public health community is needed to face this challenging problem.
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Affiliation(s)
- Alexandre Larocque
- Emergency Medicine Department, Centre Hospitalier de l'Université de Montréal, Clinical Toxicology Service, McGill University Health Center, Centre Antipoison du Québec, Montreal, Quebec, Canada.
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Agranulocytosis and other consequences due to use of illicit cocaine contaminated with levamisole. Curr Opin Hematol 2012; 19:27-31. [PMID: 22143075 DOI: 10.1097/moh.0b013e32834da9ef] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Most of the illicit cocaine consumed in the United States and elsewhere is contaminated with levamisole, a veterinary medication. Agranulocytosis caused by levamisole exposure through cocaine abuse was first described in 2009. Since then, levamisole has also been shown and is known to cause vascular and neurologic complications. In this review, we provide an overview of the medical consequences of exposure to levamisole from adulterated cocaine. RECENT FINDINGS Within the past year, several new case series have deepened our understanding of the levamisole-agranulocytosis vasculopathy syndrome. The common nature of this exposure has been delineated, cocaine contaminated with levamisole. Significant controversy surrounds the role of granulocyte colony stimulating factor (GCSF) in levamisole-associated agranulocytosis. SUMMARY More than three fourths of cocaine users in the United States are exposed to levamisole; a significant minority of these individuals will develop autoimmune-mediated neutropenia, cutaneous vascular complications, and/or leukoencephalopathy. Levamisole exposure should be considered in the differential diagnosis of patients who present with these conditions in the setting of cocaine abuse. Neutropenia appears to resolve rapidly with cessation of exposure, so that GCSF therapy and a work-up for other causes may not be needed in all patients.
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