1
|
Pendolino AL, Benshetrit G, Navaratnam AV, To C, Bandino F, Scarpa B, Kwame I, Ludwig DR, McAdoo S, Kuchai R, Gane S, Saleh H, Pusey CD, Randhawa PS, Andrews PJ. The role of ANCA in the management of cocaine-induced midline destructive lesions or ENT pseudo-granulomatosis with polyangiitis: a London multicentre case series. Laryngoscope 2024; 134:2609-2616. [PMID: 38084793 DOI: 10.1002/lary.31219] [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: 07/26/2023] [Revised: 11/07/2023] [Accepted: 11/21/2023] [Indexed: 05/09/2024]
Abstract
OBJECTIVE In this multicentric study involving three London hospitals, we compared ANCA-positive and ANCA-negative cocaine-induced midline destructive lesions (CIMDL) patients to assess how presence of antineutrophil cytoplasmic antibodies (ANCA) may correlate with disease severity. Our secondary aims are to better classify etiology centered around ANCA positivity and, consequently, better disease management. METHODS A retrospective review was performed to identify patients with CIMDL seen between January 2019 and December 2022. Population data including age, sex, presentation, endoscopic findings, duration of cocaine use and active use of cocaine, type of treatment, laboratory (including ANCA serology), radiological, and histological findings were collected. RESULTS Forty CIMDL patients (25 male, median age of 42 years) were identified. The majority of them (72.5%) presented with either a septal perforation, a saddle nose deformity (22.5%), and/or a palatal fistula (20.0%). ANCA was positive in 71.1% of cases (66.7% p-ANCA). No statistically significant differences in the general characteristics, type of treatment, laboratory results, radiological or histological findings were observed when comparing ANCA-positive and ANCA-negative CIMDL patients or when comparing p-ANCA and c-ANCA patients. Similarly, no statistically significant difference was obtained when comparing the pattern of distribution of lesions between the two groups. CONCLUSIONS A large percentage of CIMDL patients showed positive ANCA test (71.1%) and in the majority of the cases a p-ANCA pattern specifically targeting PR3 (p-ANCA, PR3 + MPO-). However, ANCA positivity or presence of a specific ANCA pattern was not associated with more severe presentation or more aggressive disease. Given its similarities to granulomatosis with polyangiitis (GPA), we recommend the use of the term "cocaine-induced ENT pseudo-GPA" instead of CIMDL. LEVEL OF EVIDENCE IV Laryngoscope, 134:2609-2616, 2024.
Collapse
Affiliation(s)
- Alfonso Luca Pendolino
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, UK
- Ear Institute, UCL, London, UK
| | - Guy Benshetrit
- Department of ENT, Imperial College Hospitals, London, UK
| | | | - Caroline To
- Department of Allergy, Royal Brompton Hospital, London, UK
- Department of Immunology and Allergy, Princess Alexandra Hospital, Brisbane, Australia
| | - Fabrizio Bandino
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, UK
| | - Bruno Scarpa
- Department of Statistical Sciences and Department of Mathematics Tullio Levi-Civita, University of Padova, Padova, Italy
| | - Ivor Kwame
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, UK
| | - Dalia R Ludwig
- Rheumatology Department, University College London Hospitals, London, UK
| | - Stephen McAdoo
- Department of ENT, Imperial College Hospitals, London, UK
| | - Romana Kuchai
- Department of ENT, Imperial College Hospitals, London, UK
| | - Simon Gane
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, UK
| | - Hesham Saleh
- Department of ENT, Imperial College Hospitals, London, UK
| | - Charles D Pusey
- Department of ENT, Imperial College Hospitals, London, UK
- Renal Department, Imperial College Hospitals, London, UK
| | - Premjit S Randhawa
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, UK
| | - Peter J Andrews
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, UK
- Ear Institute, UCL, London, UK
| |
Collapse
|
2
|
Hellwege RS, Sitter T, Wörnle M. [Vasculitis oft the skin after cocaine use]. Dtsch Med Wochenschr 2023; 148:1182-1186. [PMID: 37657456 DOI: 10.1055/a-2142-1530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Abstract
HISTORY AND CLINICAL FINDINGS A 20-years-old patient presented himself to our emergency room with extensive and extremely painful purpura with necrotizing spots and blisters, especially on the lower extremities, but also on the arms, trunk and ears. There was a pre-existing use of cocaine. MEDICAL EXAMINATIONS Laboratory tests showed increased signs of inflammation as well as an increase in proteinase 3- and myeloperoxidase-ANCA (Anti-neutrophil cytoplasmatic antibody). DIAGNOSIS In combination with the medical history, the clinical findings, and the laboratory values, vasculitis of the skin after cocaine use was revealed. THERAPY AND COURSE Under therapy with steroids and cocaine abstinence, there was a regression of the changes. CONCLUSION Vasculitis is a serious complication of cocaine use.
Collapse
Affiliation(s)
| | - Thomas Sitter
- Medizinische Klinik und Poliklinik IV, LMU Klinikum Campus Innenstadt, Ludwig-Maximilians-Universität München
| | - Markus Wörnle
- Zentrale Notaufnahme, LMU Klinikum Campus Innenstadt, Ludwig-Maximilians-Universität München, München, GERMANY
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Adegoke O, Zolotovskaya S, Abdolvand A, Daeid NN. Fabrication of a near-infrared fluorescence-emitting SiO2-AuZnFeSeS quantum dots-molecularly imprinted polymer nanocomposite for the ultrasensitive fluorescence detection of levamisole. Colloids Surf A Physicochem Eng Asp 2022. [DOI: 10.1016/j.colsurfa.2022.129013] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
5
|
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.
Collapse
|
6
|
Mbuyi N, Cunha JS. A Middle-Aged Woman With Necrotic Breast Lesions. Arthritis Care Res (Hoboken) 2019; 73:462-470. [PMID: 31651087 DOI: 10.1002/acr.24099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 10/22/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Nadine Mbuyi
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Joanne S Cunha
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| |
Collapse
|
7
|
Abstract
Levamisole is a veterinary antihelminthic, chemotherapeutic agent, and immunomodulator that also is used as an adulterant and cutting agent in cocaine distribution. This drug may potentiate the sympathomimetic actions of cocaine and can cause neutropenia, agranulocytosis, purpuric retiform lesions, and skin necrosis. This article describes two cases of suspected levamisole-induced vasculitis. No standardized diagnostic or treatment algorithm exists for this challenging condition. Diagnosis and treatment require a multidisciplinary team approach.
Collapse
|
8
|
Clinical Profile of Levamisole-Adulterated Cocaine-Induced Vasculitis/Vasculopathy. J Clin Rheumatol 2019; 25:e16-e26. [DOI: 10.1097/rhu.0000000000000813] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
9
|
Jin Q, Kant S, Alhariri J, Geetha D. Levamisole adulterated cocaine associated ANCA vasculitis: review of literature and update on pathogenesis. J Community Hosp Intern Med Perspect 2018; 8:339-344. [PMID: 30559941 PMCID: PMC6292360 DOI: 10.1080/20009666.2018.1536242] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 10/09/2018] [Indexed: 12/27/2022] Open
Abstract
Levamisole is an antihelminth drug and a common cocaine contaminant, present in an estimated 71% of cocaine samples in the US. Levamisole-contaminated cocaine has been linked to an ANCA-associated vasculitis with cutaneous, renal, and pulmonary manifestations. We report the case of a 46 year old woman with known cocaine exposure who presents with recurrent, large purpuric and maculopapular rash of the extremities and face and review existing cases of levamisole/cocaine-associated ANCA vasculitis, We summarize the clinical presentation, treatment, and outcomes of levamisole induced vasculitis. There is emerging research on pathogenesis relating to neutrophil extracellular traps (NETs). We review studies implicating role of NETs in the pathogenesis of levamisole induced vasculitis. Further research to explore the use of NETs as therapeutic targets in drug induced vasculitis is needed.
Collapse
Affiliation(s)
- Qiuyu Jin
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sam Kant
- Department of Medicine, University of Maryland Medical Center, Baltimore, MD, USA
| | - Jihad Alhariri
- Division of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
10
|
Surgical Management of Levamisole-Adulterated Cocaine Induced Soft Tissue Necrosis: Case Study and Treatment Algorithm. J Burn Care Res 2018; 38:e638-e646. [PMID: 27606557 DOI: 10.1097/bcr.0000000000000428] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Levamisole is an increasingly common cocaine adulterant that can cause severe and rapid onset cutaneous vasculitis in humans. While most cases may be managed conservatively, we describe a series of patients in whom the extent of skin and soft tissue necrosis mandated surgical intervention. A retrospective review of all patients admitted to one of two regional burn centers between 2006 and 2016 for soft tissue necrosis after exposure to levamisole-adulterated cocaine was included in our study. Ten patients, majority female (9/10) with an average age of 43.4 years (range 31-57), were included. Cocaine usage before presentation averaged 6 days (range 1-14). Presenting complaints consisted of arthralgia (5/10), fever (7/10), and purpuric lesions (10/10). Average TBSA involvement was 23.5% (range 4-70). Immunological testing revealed perinuclear antineutrophil cytoplasmic antibody (pANCA+) in 8 of 10 and cytoplasmic antineutrophil cytoplasmic antibody (cANCA+) in 4 of 8 patients. Operative intervention occurred by postadmission day 11.6 (range 3-30). The mean number of operations required was 3 (range 2-6); length of stay averaged 46.8 days (range 14-120); and survival to discharge was 100% (10/10). To our knowledge, this is the largest case study detailing the surgical management of levamisole-associated skin necrosis. Additionally, we describe the most extensive case of this disease process at 70% TBSA involvement. Based on our experience, we recommend waiting for purpuric rash resolution and soft tissue necrosis to be fully demarcated before fascial debridement and then staged skin grafting with allograft followed by autograft.
Collapse
|
11
|
Roshan B, Knezevich S, Mu A. A 54-Year-Old Woman With Bacteremia and an Unusual Rash. Clin Infect Dis 2017. [DOI: 10.1093/cid/cix384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Bakht Roshan
- Division of Infectious Diseases, University of California San Francisco, Fresno Medical Education Program
| | | | - Anandit Mu
- Division of Infectious Diseases, University of California San Francisco, Fresno Medical Education Program
| |
Collapse
|
12
|
Mohan V, Maiti A, Swaby MG, Cherian SV. Vasculitis due to levamisole-adulterated cocaine. Postgrad Med J 2017; 94:61. [PMID: 28972099 DOI: 10.1136/postgradmedj-2017-135162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 08/17/2017] [Accepted: 09/17/2017] [Indexed: 11/03/2022]
Affiliation(s)
- Vishnu Mohan
- Department of Internal Medicine, The University of Texas Health Science Centre at Houston, Houston, Texas, USA
| | - Abhishek Maiti
- Department of Internal Medicine, The University of Texas Health Science Centre at Houston, Houston, Texas, USA
| | - Michael G Swaby
- Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Sujith V Cherian
- Department of Internal Medicine, The University of Texas Health Science Centre at Houston, Houston, Texas, USA
- Department of Internal Medicine, Division of Critical Care, Pulmonary and Sleep Medicine, The University of Texas Health Science Centre at Houston, Houston, Texas, USA
| |
Collapse
|
13
|
Marquez J, Aguirre L, Muñoz C, Echeverri A, Restrepo M, Pinto LF. Cocaine-Levamisole-Induced Vasculitis/Vasculopathy Syndrome. Curr Rheumatol Rep 2017; 19:36. [DOI: 10.1007/s11926-017-0653-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
14
|
|
15
|
Sena LCS, Matos HR, Dórea HS, Pimentel MF, de Santana DCAS, de Santana FJM. Dispersive liquid-liquid microextraction based on solidification of floating organic drop and high-performance liquid chromatography to the analysis of cocaine’s major adulterants in human urine. Toxicology 2017; 376:102-112. [DOI: 10.1016/j.tox.2016.04.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 03/05/2016] [Accepted: 04/25/2016] [Indexed: 10/21/2022]
|
16
|
Cutaneous Necrotizing Vasculitis and Leukopenia in a Cocaine User: Is Levamisole the Culprit? Case Rep Rheumatol 2016; 2016:2685267. [PMID: 27579207 PMCID: PMC4992510 DOI: 10.1155/2016/2685267] [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: 04/29/2016] [Accepted: 06/20/2016] [Indexed: 12/05/2022] Open
Abstract
Levamisole is an antihelminthic drug banned by the US Food and Drug Administration (FDA) in 2000 because of its dangerous side effects. Over the past few years, it has been identified as an adulterant in cocaine and reported to cause cutaneous vasculitis in cocaine users. The health burden of levamisole is serious since it is estimated that over 5 million Americans use cocaine and that 70% of the cocaine used in the USA contains levamisole. In this paper we report the case of a 23-year-old female cocaine user that presented with purpuric rash and skin necrosis, found to have positive c-ANCA and anti-proteinase 3 antibodies. Her skin biopsy showed fibroconnective tissue with signs of necrosis, acute and chronic inflammation, and thrombus formation. She was diagnosed with levamisole-induced vasculitis and successfully treated with withdrawal of cocaine use and local wound care.
Collapse
|
17
|
Haskin A, Kim N, Aguh C. Reply to: “Commentary on ‘A new drug with a nasty bite: A case of krokodil-induced skin necrosis in an intravenous drug user’”. JAAD Case Rep 2016; 2:424. [PMID: 27872892 PMCID: PMC5109848 DOI: 10.1016/j.jdcr.2016.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
| | - Noori Kim
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Crystal Aguh
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, Maryland
- Correspondence to: Crystal Aguh, MD, Assistant Professor of Dermatology, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Mason F. Lord Bldg Center Tower Suite 2500, 5200 Eastern Ave, Baltimore, MD 21224Johns Hopkins School of MedicineJohns Hopkins Bayview Medical CenterMason F. Lord Bldg Center Tower Suite 25005200 Eastern AveBaltimoreMD21224
| |
Collapse
|
18
|
Le Garff E, Tournel G, Becquart C, Cottencin O, Dupin N, Delaporte E, Hedouin V. Extensive Necrotic Purpura in Levamisole-Adulterated Cocaine Abuse - A Case Report. J Forensic Sci 2016; 61:1681-1685. [PMID: 27500987 DOI: 10.1111/1556-4029.13176] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 01/26/2016] [Accepted: 01/30/2016] [Indexed: 11/28/2022]
Abstract
Levamisole, which is used as an adulterated compound of cocaine, is currently being seen year after year in cocaine intoxication. For a few cases in the last decade, necrotic purpura and neutropenia after levamisole/cocaine intoxication have been described in the medical community. Herein, we present an original case of levamisole intoxication of a 40-year-old woman who smoked heroin and cocaine few during a month. She rapidly presented an extensive necrotic purpura of the nose, cheeks and extremities (lower and upper), and immunologic reactions (positive anti-MPO and anti-HNE). Levamisole was detected on hairs with ultra-high performance liquid chromatography and tandem mass spectrometry. The case reports also a probable cocaine supplier deceit, which bring pure drug for hospital investigation after the intoxication of his client. The intoxicated woman had survived with several skin and chronic pain complications. That case recalls the knowledge about levamisole with a short review of the forensic literature.
Collapse
Affiliation(s)
- Erwan Le Garff
- Service de Médecine Légale, CHU Lille, University Lille, UTML 7367, F-59000, Lille, France
| | - Gilles Tournel
- Service de Médecine Légale, CHU Lille, University Lille, UTML 7367, F-59000, Lille, France.,Service de toxicologie, CHU Lille, University Lille, F-59000, Lille, France
| | - Coralie Becquart
- Service de dermatologie, CHU Lille, University Lille, F-59000, Lille, France
| | - Olivier Cottencin
- ScaLab CNRS UMR 9193, Service d'addictologie, CHU Lille, University Lille, F-59000, Lille, France
| | - Nicolas Dupin
- Service de dermatologie, CHU Cochin, Rue du Faubourg St Jacques, 75014, Paris, France
| | - Emmanuel Delaporte
- Service de dermatologie, CHU Lille, University Lille, F-59000, Lille, France
| | - Valéry Hedouin
- Service de Médecine Légale, CHU Lille, University Lille, UTML 7367, F-59000, Lille, France
| |
Collapse
|
19
|
Riley ED, Kral AH, Cohen J, Dilworth SE, Shumway M, Lynch KL. Levamisole-Contaminated Cocaine Use in HIV-Infected and Uninfected Unstably Housed Women. J Womens Health (Larchmt) 2016; 25:936-43. [PMID: 27203838 DOI: 10.1089/jwh.2015.5532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A growing number of case reports cite serious health complications linked to the cocaine adulterant, levamisole and women are disproportionately affected; however, the clinical effects are not well established. Between April and October of 2010, we conducted a cross-sectional study among 222 homeless and unstably housed women (116 human immunodeficiency virus [HIV]-infected and 106 HIV-uninfected). Immune markers and behavioral factors were compared in separate models by cocaine and levamisole exposure. Overall, 63% of participants were toxicology positive for cocaine/benzoylecgonine, 85% of whom also tested positive for levamisole. Differences in immune markers did not reach levels of significance among HIV-uninfected persons. Compared to HIV-infected persons who were negative for both cocaine and levamisole, the adjusted odds of low white blood cell count were significantly higher among HIV-infected persons positive for both (p = 0.03), but not for those positive for cocaine only. Neutrophil count and HIV viral load did not differ by cocaine and levamisole status among HIV-infected persons. In a separate model, the adjusted odds of testing positive for levamisole were higher among African American women compared to Caucasian and Asian women (p = 0.02). In the context of high levamisole prevalence, results suggest that decreased immune function as a result of levamisole exposure occurs mainly in individuals who are already immune compromised (e.g., HIV-positive), and race/ethnicity appears to be an important factor in understanding levamisole exposure among cocaine-using women. While larger and geographically diverse studies are needed to elucidate these initial findings, results suggest that levamisole may be one mechanism of immune dysfunction in HIV-infected cocaine-using women.
Collapse
Affiliation(s)
- Elise D Riley
- 1 Department of Medicine, University of California , San Francisco, San Francisco, California
| | - Alex H Kral
- 2 RTI International, Behavioral and Urban Health Program , San Francisco, California
| | - Jennifer Cohen
- 3 Department of Clinical Pharmacy, University of California , San Francisco, San Francisco, California
| | - Samantha E Dilworth
- 1 Department of Medicine, University of California , San Francisco, San Francisco, California
| | - Martha Shumway
- 4 Department of Psychiatry, University of California , San Francisco, San Francisco, California
| | - Kara L Lynch
- 5 Department of Laboratory Medicine, University of California , San Francisco, San Francisco, California
| |
Collapse
|
20
|
Imbernón-Moya A, Chico R, Aguilar-Martínez A. [Cutaneous and mucosal manifestations associated with cocaine use]. Med Clin (Barc) 2016; 146:544-9. [PMID: 27033438 DOI: 10.1016/j.medcli.2016.02.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 02/03/2016] [Accepted: 02/04/2016] [Indexed: 10/22/2022]
Abstract
Complications due to cocaine are a public health problem. The typical cutaneous disease is leukocytoclastic vasculitis and/or thrombotic vasculopathy affecting mainly the ears. No intense systemic involvement is usually present, but there may be several cutaneous, mucosal and systemic manifestations. Other findings associated as arthralgia, neutropaenia or agranulocytosis, low titer positive antinuclear antibodies, antiphospholipid antibody positivity and neutrophil cytoplasmic antibodies against multiple antigens help the diagnosis. This disease requires a clinical suspicion with a clinical history, a complete physical examination and a broad differential diagnosis for an early and correct diagnosis. The course is usually self-limited. In most cases the only treatment is to discontinue the use of cocaine associated with symptomatic treatment, no proven benefit of systemic corticosteroids.
Collapse
Affiliation(s)
- Adrián Imbernón-Moya
- Servicio de Dermatología, Hospital Universitario Severo Ochoa, Leganés, Madrid, España.
| | - Ricardo Chico
- Servicio de Dermatología, Hospital Universitario Severo Ochoa, Leganés, Madrid, España
| | | |
Collapse
|
21
|
|
22
|
|
23
|
Roberts JA, Chévez-Barrios P. Levamisole-Induced Vasculitis: A Characteristic Cutaneous Vasculitis Associated With Levamisole-Adulterated Cocaine. Arch Pathol Lab Med 2015; 139:1058-61. [PMID: 26230600 DOI: 10.5858/arpa.2014-0107-rs] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Levamisole-induced vasculitis is a characteristic cutaneous vasculitis syndrome associated with the use of levamisole-adulterated cocaine. Patients will typically present with a painful, purpuric rash in a retiform or stellate pattern with or without central necrosis involving the extremities, trunk, nasal tip, digits, cheeks, and/or ears. A history of cocaine abuse can be elicited. Histologic features include microvascular thrombi and/or leukocytoclastic vasculitis involving small vessels of the superficial and deep dermis. Epidermal involvement is variably seen. Laboratory findings include leukopenia, neutropenia (including agranulocytosis), elevated erythrocyte sedimentation rate, normal coagulation studies, and positive autoantibodies including perinuclear and cytoplasmic antineutrophil cytoplasmic antibodies, antinuclear antibody, and lupus anticoagulant. Differential diagnosis includes other microscopic vasculitides, and clinical and laboratory correlation with histologic findings is essential. Lesions typically resolve with the cessation of cocaine use. Because of the treatment implications and rising incidence of this entity, rapid and accurate diagnosis is essential.
Collapse
Affiliation(s)
| | - Patricia Chévez-Barrios
- From the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas (Drs Roberts and Chévez-Barrios); and Weill Cornell Medical College of Cornell University, Houston, Texas (Dr Chévez-Barrios)
| |
Collapse
|
24
|
Patnaik S, Balderia P, Vanchhawng L, Markazi P, Wykretowicz J, Perloff S. Is Levamisole-Induced Vasculitis a Relegated Diagnostic Possibility? A Case Report and Review of Literature. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:658-62. [PMID: 26406869 PMCID: PMC4588636 DOI: 10.12659/ajcr.894537] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Patient: Female, 38 Final Diagnosis: Levamisole induced vasculitis Symptoms: Skin and joint Medication: — Clinical Procedure: None Specialty: Toxicology
Collapse
Affiliation(s)
- Soumya Patnaik
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA, USA
| | - Percy Balderia
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA, USA
| | - Lisa Vanchhawng
- Department of Medicine, Division of Infectious Disease, Albert Einstein Medical Center, Philadelphia, PA, USA
| | - Peyman Markazi
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA, USA
| | - Jedrzej Wykretowicz
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA, USA
| | - Sarah Perloff
- Department of Medicine, Division of Infectious Disease, Albert Einstein Medical Center, Philadelphia, PA, USA
| |
Collapse
|
25
|
Yogarajah M, Pervil-Ulysse M, Sivasambu B. Cocaine-induced delayed recurrent vasculitis: a 4-year follow-up. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:310-4. [PMID: 26003170 PMCID: PMC4456982 DOI: 10.12659/ajcr.893550] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 02/12/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND Cocaine is a highly abused substance in United States with almost 70 % of cocaine adulterated with levamisole. It is known to cause vasculitis involving multiple organs due to its direct toxic effect and by the contribution of levamisole or a combined effect of both. CASE REPORT A 51-year-old woman complained of painful erythematous rash in her hands and lower extremities that started few hours after smoking cocaine and progressed to blistering dark lesions in her lower extremities. She denied any other systemic complaints. Although she has been smoking cocaine for more than 35 years, these skin eruptions started only 4 years ago. Examination revealed tender retiform purpura in the hand and tender retiform purpura with hemorrhagic bulla in the legs. Initially, she had only a significantly positive atypical p-ANCA and later developed combined positivity of both Myeloperoxidase (MPO) and Anti-proteinase-3(PR3) antibodies with a p-ANCA pattern on immunofluorescence. We report a unique case of cocaine (likely contaminated with levamisole)-induced delayed recurrent vasculitis with varying vasculitic antibodies over the years. CONCLUSIONS This case highlights the fact that patients can develop cocaine-related vasculitis after many years of uneventful abuse. Cocaine, with its adulterant levamisole, has the propensity to trigger diverse immunological reactions, which is evident by the varying antibody profile seen in the same patient over time.
Collapse
|
26
|
Tallarida CS, Tallarida RJ, Rawls SM. Levamisole enhances the rewarding and locomotor-activating effects of cocaine in rats. Drug Alcohol Depend 2015; 149:145-50. [PMID: 25683823 PMCID: PMC4447121 DOI: 10.1016/j.drugalcdep.2015.01.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 01/24/2015] [Accepted: 01/25/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND The Drug Enforcement Agency estimates that 80% of cocaine seized in the United States contains the veterinary pharmaceutical levamisole (LVM). One problem with LVM is that it is producing life-threatening neutropenia in an alarming number of cocaine abusers. The neuropharmacological profile of LVM is also suggestive of an agent with modest reinforcing and stimulant effects that could enhance cocaine's addictive effects. METHODS We tested the hypothesis that LVM (ip) enhances the rewarding and locomotor stimulant effects of cocaine (ip) using rat conditioned place preference (CPP) and locomotor assays. Effects of LVM by itself were also tested. RESULTS LVM (0-10 mg/kg) produced CPP at 1mg/kg (P<0.05) and locomotor activation at 5mg/kg (P < 0.05). For CPP combination experiments, a statistically inactive dose of LVM (0.1 mg/kg) was administered with a low dose of cocaine (2.5 mg/kg). Neither agent produced CPP compared to saline (P > 0.05); however, the combination of LVM and cocaine produced enhanced CPP compared to saline or either drug by itself (P < 0.01). For locomotor experiments, the same inactive dose of LVM (0.1mg/kg, ip) was administered with low (10 mg/kg) and high doses (30 mg/kg) of cocaine. LVM (0.1 mg/kg) enhanced locomotor activation produced by 10mg/kg of cocaine (P < 0.05) but not by 30 mg/kg (P>0.05). CONCLUSIONS LVM can enhance rewarding and locomotor-activating effects of low doses of cocaine in rats while possessing modest activity of its own.
Collapse
Affiliation(s)
- Christopher S Tallarida
- Center for Substance Abuse Research, Temple University School of Medicine, Philadelphia, PA, USA; Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, USA
| | - Ronald J Tallarida
- Center for Substance Abuse Research, Temple University School of Medicine, Philadelphia, PA, USA; Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, USA
| | - Scott M Rawls
- Center for Substance Abuse Research, Temple University School of Medicine, Philadelphia, PA, USA; Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, USA.
| |
Collapse
|
27
|
Lawrence LA, Jiron JL, Lin HS, Folbe AJ. Levamisole-adulterated cocaine induced skin necrosis of nose, ears, and extremities: Case report. ALLERGY & RHINOLOGY 2015; 5:132-6. [PMID: 25565048 PMCID: PMC4275458 DOI: 10.2500/ar.2014.5.0101] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Levamisole is an immunomodulatory and antihelminthic drug, previously removed from the United States market, and now estimated to be present in the vast majority of cocaine distributed in the United States. Levamisole-adulterated cocaine (LAC) exposure can result in neutropenia, thrombocytopenia, and vasculitis with a predilection for subsites of the face. The objective of this review is to increase awareness among otolaryngologists of the manifestations of LAC exposure. We present the case of a 33-year-old woman with a history of cocaine use, consulted for purpuric, necrotic lesions of the nose, cheeks, and ears, with accompanying leukopenia, thrombocytopenia, and positive antineutrophil cytoplasmic antibodies (ANCA). The effects of levamisole are immune mediated, with antibodies directed against neutrophils causing neutropenia, and vasculitis caused by antibody deposition or secondary to induction of antiphospholipid antibodies causing thrombosis. LAC exposure can be differentiated from other similar appearing pathologies by evaluating serology for specific ANCA. The most important treatment is cessation of cocaine use, which most often results in complete resolution of symptoms. Awareness of the presentation, complications, and treatment of LAC exposure may be especially important for otolaryngologists, who may be one of the firsts to evaluate an affected patient.
Collapse
Affiliation(s)
- Lauren A Lawrence
- Department of Otolaryngology, Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, USA
| | | | | | | |
Collapse
|
28
|
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.
Collapse
|
29
|
Tallarida CS, Egan E, Alejo GD, Raffa R, Tallarida RJ, Rawls SM. Levamisole and cocaine synergism: a prevalent adulterant enhances cocaine's action in vivo. Neuropharmacology 2014; 79:590-5. [PMID: 24440755 DOI: 10.1016/j.neuropharm.2014.01.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 01/02/2014] [Accepted: 01/04/2014] [Indexed: 01/17/2023]
Abstract
Levamisole is estimated by the Drug Enforcement Agency (DEA) to be present in about 80% of cocaine seized in the United States and linked to debilitating, and sometimes fatal, immunologic effects in cocaine abusers. One explanation for the addition of levamisole to cocaine is that it increases the amount of product and enhances profits. An alternative possibility, and one investigated here, is that levamisole alters cocaine's action in vivo. We specifically investigated effects of levamisole on cocaine's stereotypical and place-conditioning effects in an established invertebrate (planarian) assay. Acute exposure to levamisole or cocaine produced concentration-dependent increases in stereotyped movements. For combined administration of the two agents, isobolographic analysis revealed that the observed stereotypical response was enhanced relative to the predicted effect, indicating synergism for the interaction. In conditioned place preference (CPP) experiments, cocaine produced a significant preference shift; in contrast, levamisole was ineffective at all concentrations tested. For combination experiments, a submaximal concentration of cocaine produced CPP that was enhanced by inactive concentrations of levamisole, indicating synergism. The present results provide the first experimental evidence that levamisole enhances cocaine's action in vivo. Most important is the identification of synergism for the levamisole/cocaine interaction, which now requires further study in mammals.
Collapse
Affiliation(s)
- Christopher S Tallarida
- Center for Substance Abuse Research, Temple University School of Medicine, Philadelphia, PA, USA; Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, USA
| | - Erin Egan
- Center for Substance Abuse Research, Temple University School of Medicine, Philadelphia, PA, USA; Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, USA
| | - Gissel D Alejo
- Center for Substance Abuse Research, Temple University School of Medicine, Philadelphia, PA, USA; Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, USA
| | - Robert Raffa
- Center for Substance Abuse Research, Temple University School of Medicine, Philadelphia, PA, USA; Department of Pharmaceutical Sciences, Temple University School of Pharmacy, Philadelphia, PA, USA
| | - Ronald J Tallarida
- Center for Substance Abuse Research, Temple University School of Medicine, Philadelphia, PA, USA; Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, USA
| | - Scott M Rawls
- Center for Substance Abuse Research, Temple University School of Medicine, Philadelphia, PA, USA; Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, USA.
| |
Collapse
|
30
|
Jiménez-Gallo D, Albarrán-Planelles C, Linares-Barrios M, Rodríguez-Hernández C, Martínez-Rodríguez A, García-Moreno E, Bravo-Monge R. Pyoderma gangrenosum and Wegener granulomatosis-like syndrome induced by cocaine. Clin Exp Dermatol 2013; 38:878-82. [PMID: 24252079 DOI: 10.1111/ced.12207] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2013] [Indexed: 11/29/2022]
Abstract
Cocaine abuse is associated with various skin and rheumatological diseases that mimic primary autoimmune diseases, including retiform purpura with involvement of the ears, cocaine-induced midline destructive lesions (CIMDL), and eruptive pyoderma gangrenosum (PG). Previous reports have suggested the use of perinuclear antineutrophil cytoplasmic antibodies (pANCA) with specificity against human neutrophil elastase (HNE) to differentiate these cocaine-induced diseases from primary autoimmune diseases. We describe a case of a 54-year-old woman with a history of cocaine abuse, who had PG lesions on her legs with accompanying CIMDL and lung lesions similar to those seen in Wegener granulomatosis. Detection of HNE-positive pANCA, and improvement or clinical recurrence after cessation or consumption of cocaine, respectively, were key to differentiating this presentation from primary autoimmune disease.
Collapse
Affiliation(s)
- D Jiménez-Gallo
- Department of Dermatology, Puerta del March University Hospital, Cadiz, Spain
| | | | | | | | | | | | | |
Collapse
|
31
|
García Pérez MR, Ortiz-González VL, Betancourt M, Mercado R. Cocaine-induced vasculitis: is this a new trend? Open Access Rheumatol 2013; 5:77-80. [PMID: 27790026 PMCID: PMC5074789 DOI: 10.2147/oarrr.s51524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Cocaine-induced vasculitis is a rare complication found in drug abusers. It occurs due to cocaine adulterated with levamisole. Levamisole was once used as a chemotherapy and immunomodulator for different conditions. One of the side effects of this medication is necrotizing vasculitis which has been reported in the US and Puerto Rico. Here we present another case of cocaine induced vasculitis in Puerto Rico. We describe a 43-year-old female with past medical history of bronchial asthma, migraine, and crack smoking who presented to the emergency room due to blood in her urine for 5 days. She also reported fever, chills, and fatigue. At the physical exam she had a right knee ulcer with swelling erythema, warmth, and pain. Also, she had retiform purpuric plaque lesions in her ears, bilaterally. Eroded plaques with elevated borders at left foot and finger dorsum were also present. Laboratory workup was positive for cocaine. The patient showed leucopenia and microcytic anemia with a normal absolute neutrophil count in her cell blood count. Blood cultures, urine cultures, and ulcer cultures were negative. Urinalysis was positive for proteinuria and hematuria. Also, the patient had positive perinuclear anti-neutrophil cytoplasmic antibody, cytoplasmic anti-neutrophil cytoplasmic antibody, and antinuclear antibody tests and elastase specificity. She showed negative anticardiolipin and lupus anticoagulant antibodies. Her complement levels were decreased. The punch biopsy of her ear showed superficial thrombosis of superficial vascular plexus with perivascular lymphocytic infiltrates and deeper sections showed epidermal necrosis and necrotizing vasculitis. She was started on a high dose of steroids, but could not complete the treatment because she escaped from the hospital before finishing her treatment.
Collapse
Affiliation(s)
| | | | | | - Rogelio Mercado
- Department of Dermatology, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
| |
Collapse
|
32
|
Rubin K. The manifestation of cocaine-induced midline destructive lesion in bone tissue and its identification in human skeletal remains. Forensic Sci Int 2013; 231:408.e1-11. [PMID: 23706264 DOI: 10.1016/j.forsciint.2013.04.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 02/16/2013] [Accepted: 04/21/2013] [Indexed: 11/18/2022]
Abstract
Cocaine-induced midline destructive lesion (CIMDL) is a condition that may arise in response to chronic insufflation ("snorting") of cocaine. It is clinically diagnosed when the nasal septum, lateral nasal walls, and/or hard palate show signs of destruction in association with cocaine use. Although its true incidence is unknown, CIMDL is not an uncommon clinical finding amongst intranasal cocaine abusers and is likely to be encountered by forensic anthropologists and medical examiners working worldwide. Given the preponderance of drug abusers amongst the subjects of forensic casework, the ability to diagnose CIMDL in dry bone may provide crucial insight into an investigation and even help confirm an individual identification. This paper aims to make practicing forensic anthropologists aware of CIMDL. Through the analysis of existing clinical literature, patient CT scans, and histology sections, it works toward the establishment of formal diagnostic criteria for identifying CIMDL in human skeletal remains. Lytic destruction regularly involves the vomer and frequently extends to the perpendicular plate of the ethmoid, the palatal process of the maxillae or the palatine bones, and the inferior nasal conchae. The middle nasal conchae, medial walls of the maxillary sinuses, ethmoid sinuses, and cribriform plate are often damaged. Destruction may also implicate the superior nasal conchae, the orbit, and the sphenoid. Bones affected by CIMDL may contain necrotic lesions or may be absent entirely. Lesions show minimal, if any, signs of repair. The author proposes that this lack of new bone formation may be mediated by potentially elevated leptin levels in cocaine abusers and CIMDL patients and may be the key to differentiating CIMDL from other lytic processes of the midface.
Collapse
Affiliation(s)
- Katie Rubin
- University of Pennsylvania, Department of Anthropology, University Museum, Room 325, 3260 South Street, Philadelphia, PA 19104, USA.
| |
Collapse
|
33
|
Abstract
Levamisole-contaminated cocaine has recently been recognized in North America and Europe, and its use is associated with a variety of clinical and autoimmune abnormalities. The clinical characteristic seems to be the presence of a painful purpuric skin rash that predominantly affects the ear lobes and cheeks, often accompanied by systemic manifestations including fever, malaise, arthralgias, myalgias, and laboratory abnormalities, for example leukopenia, neutropenia, positive ANA, ANCA, and phospholipid antibodies. Most of these manifestations can be seen with the use of either drug, especially levamisole. There is no specific therapy, and discontinuation of its use is followed by improvement. Prednisone and immunosuppressive therapy may be needed at times. Further use of the drug is characterized by recurrence of most of the complaints.
Collapse
|
34
|
Gaffo AL. Thrombosis in vasculitis. Best Pract Res Clin Rheumatol 2013; 27:57-67. [PMID: 23507057 DOI: 10.1016/j.berh.2012.12.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Revised: 12/28/2012] [Accepted: 12/30/2012] [Indexed: 12/12/2022]
Abstract
Thrombo-embolic disease is an increasingly recognised complication of several vasculitides. A common observation is that thrombo-embolic complications coincide with periods of increased vasculitis disease activity, but the mechanism through which this happens is still unknown. Thrombo-embolic disease has been recognised for decades as a significant contributor to the morbidity and mortality of Behçet's disease, and the role of anticoagulation in its management is being minimised in favour of immunosuppression, although evidence from randomised controlled trials is lacking. Ancillary data from a randomised clinical trial and retrospective observational studies have confirmed an association between venous thrombo-embolic disease and vasculitides associated with anti-neutrophil cytoplasmic antibodies (ANCAs). An increased cardiovascular risk is now also recognised for vasculitides associated with ANCAs. Thrombosis plays a prominent role in the pathogenesis of thromboangiitis obliterans (Buerger's disease). The association of thrombosis with other vasculitides such as giant-cell arteritis and levamisole-induced vasculopathy is under investigation.
Collapse
Affiliation(s)
- Angelo L Gaffo
- Rheumatology Section, Veterans Affairs Medical Center, Birmingham, AL, USA.
| |
Collapse
|
35
|
Xiao Y, Li J, Fu C. A sensitive method for the determination of levamisole in serum by electrochemiluminescence. LUMINESCENCE 2013; 29:183-7. [PMID: 23649929 DOI: 10.1002/bio.2527] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 03/08/2013] [Accepted: 03/28/2013] [Indexed: 12/28/2022]
Abstract
A novel method was developed for the determination of levamisole by electrochemiluminescence. The method was based on electrochemiluminescence signal enhancement produced by Ru(bpy)(3)(2+), which reacted with the tertiary amine group of levamisole on a platinum electrode in 12 mmol/L borate buffer (pH 9). A linear relationship between the luminous intensity and concentration of levamisole in the range 0-1 × 10(-7) mol/L was obtained and the detection limit was 1.76 × 10(-11) mol/L. The method is sensitive, selective, simple and convenient. The method has been successfully applied to the analysis of levamisole in serum.
Collapse
Affiliation(s)
- Ying Xiao
- College of Chemistry and Bioengineering, Guilin University of Technology, Guilin, Guangxi, 541004, China
| | | | | |
Collapse
|
36
|
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.
Collapse
|
37
|
Carter MR, Amirhaeri S. p-ANCA-Associated Vasculitis Caused by Levamisole-Adulterated Cocaine: A Case Report. Case Rep Emerg Med 2013; 2013:878903. [PMID: 23476825 PMCID: PMC3580925 DOI: 10.1155/2013/878903] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Accepted: 01/10/2013] [Indexed: 11/18/2022] Open
Abstract
A rare case of a patient with an unusual skin rash after using cocaine is presented. A clinical diagnosis of levamisole-induced vasculitis was made based on initial presentation of purpuric skin lesions involving the ears and positive cocaine on urine toxicology screening. The diagnosis was confirmed after laboratory findings of neutropenia, positive serum levamisole, and a histopathologic test of the skin lesions. The pathophysiology of this condition is discussed. Treatment with methylprednisolone and prednisone led to the resolution of the neutropenia and complete recovery of the skin lesions. With the growing use of levamisole-tainted cocaine, clinicians should be aware of the symptoms of vasculitis and neutropenia induced by this combination of drugs to avoid unnecessary tests and delayed diagnosis.
Collapse
Affiliation(s)
- Michelle R. Carter
- Department of Emergency Medicine, Howard University Hospital, 2041 Georgia Avenue, Washington, DC 20060, USA
| | - Sorour Amirhaeri
- Department of Emergency Medicine, Howard University Hospital, 2041 Georgia Avenue, Washington, DC 20060, USA
| |
Collapse
|
38
|
Abstract
We report a case of cutaneous vasculopathy associated with the use of levamisole-adulterated cocaine. This recently described clinical entity is characterized by a purpuric rash with a predilection for the ears, leukopenia, and anti-neutrophilic cytoplasmic antibody (ANCA) positivity. It is estimated that more than 70% of the current United States cocaine supply is contaminated with levamisole. Levamisole is a widely available, inexpensive, white powder used as a "cutting agent" in cocaine to expand volume and increase profits. It may also increase the euphoric and stimulatory effects of cocaine by increasing brain dopamine levels and producing amphetamine-like metabolites. Our patient exhibited a characteristic rash with involvement of the ears, leukopenia, and cocaine metabolites were detected in serum and urine. The presence of levamisole was confirmed in the urine utilizing gas chromatography-mass spectrometry. ANCA positivity was also present. Punch biopsy of the skin demonstrated vascular thrombosis and necrosis without true vasculitis. We review the literature for reported cases of cocaine-levamisole cutaneous vasculopathy syndrome, highlight the salient immunologic abnormalities, and contrast the features of this entity with idiopathic systemic vasculitis.
Collapse
Affiliation(s)
- Huy Tran
- Internal Medicine Residency Program, Department of Medicine, St. Elizabeth Health Center, Youngstown, Ohio, USA
| | - Debbie Tan
- Internal Medicine Residency Program, Department of Medicine, St. Elizabeth Health Center, Youngstown, Ohio, USA
| | - Thomas P. Marnejon
- Internal Medicine Residency Program, Department of Medicine, St. Elizabeth Health Center, Youngstown, Ohio, USA
- Department of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, USA
- Corresponding Author: Thomas Marnejon, DO Department of Medicine St. Elizabeth Health Center 1044 Belmont Avenue Youngstown, OH 44501 Tel: (330) 480-3344 Fax: (330) 480-3777
| |
Collapse
|
39
|
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.
Collapse
Affiliation(s)
- Kelly R Magliocca
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA 30322, USA.
| | | | | |
Collapse
|
40
|
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.
Collapse
Affiliation(s)
- Shuchi Gulati
- Department of Internal Medicine, The Reading Hospital and Medical Center, 6th Avenue and Spruce Street, West Reading, PA 19611, USA.
| | | |
Collapse
|
41
|
|
42
|
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.
Collapse
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.
| | | | | | | |
Collapse
|
43
|
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.
Collapse
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
| | | | | | | | | | | |
Collapse
|
44
|
Lee KC, Ladizinski B, Federman DG. Complications associated with use of levamisole-contaminated cocaine: an emerging public health challenge. Mayo Clin Proc 2012; 87:581-6. [PMID: 22677078 PMCID: PMC3498128 DOI: 10.1016/j.mayocp.2012.03.010] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 03/21/2012] [Accepted: 03/27/2012] [Indexed: 10/28/2022]
Abstract
Levamisole is an immunomodulatory agent that was used to treat various cancers before being withdrawn from the United States market in 2000 because of adverse effects. Levamisole is currently approved as an antihelminthic agent in veterinary medicine, but is also being used illicitly as a cocaine adulterant. Potential complications associated with use of levamisole-laced cocaine include neutropenia, agranulocytosis, arthralgias, retiform purpura, and skin necrosis. Treatment is primarily supportive, and skin lesions typically resolve with cessation of cocaine use. The incidence of hospitalizations related to use of levamisole-contaminated cocaine continues to increase and clinicians should be aware of the more common clinical manifestations.
Collapse
Affiliation(s)
- Kachiu C. Lee
- Department of Dermatology, Brown University, Providence, RI
| | - Barry Ladizinski
- Department of Dermatology, Duke University Medical Center, Durham, NC
| | - Daniel G. Federman
- Department of Internal Medicine, VA Connecticut Healthcare System, West Haven
| |
Collapse
|
45
|
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.
Collapse
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.
| | | |
Collapse
|
46
|
Wolford A, McDonald TS, Eng H, Hansel S, Chen Y, Bauman J, Sharma R, Kalgutkar AS. Immune-mediated agranulocytosis caused by the cocaine adulterant levamisole: a case for reactive metabolite(s) involvement. Drug Metab Dispos 2012; 40:1067-75. [PMID: 22393119 DOI: 10.1124/dmd.112.045021] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
The United States Public Health Service Administration is alerting medical professionals that a substantial percentage of cocaine imported into the United States is adulterated with levamisole, a veterinary pharmaceutical that can cause blood cell disorders such as severe neutropenia and agranulocytosis. Levamisole was previously approved in combination with fluorouracil for the treatment of colon cancer; however, the drug was withdrawn from the U.S. market in 2000 because of the frequent occurrence of agranulocytosis. The detection of autoantibodies such as antithrombin (lupus anticoagulant) and an increased risk of agranulocytosis in patients carrying the human leukocyte antigen B27 genotype suggest that toxicity is immune-mediated. In this perspective, we provide an historical account of the levamisole/cocaine story as it first surfaced in 2008, including a succinct review of levamisole pharmacology, pharmacokinetics, and preclinical/clinical evidence for levamisole-induced agranulocytosis. Based on the available information on levamisole metabolism in humans, we propose that reactive metabolite formation is the rate-limiting step in the etiology of agranulocytosis associated with levamisole, in a manner similar to other drugs (e.g., propylthiouracil, methimazole, captopril, etc.) associated with blood dyscrasias. Finally, considering the toxicity associated with levamisole, we propose that the 2,3,5,6-tetrahydroimidazo[2,1-b]thiazole scaffold found in levamisole be categorized as a new structural alert, which is to be avoided in drug design.
Collapse
Affiliation(s)
- Angela Wolford
- Pharmacokinetics, Dynamics, and Metabolism Department, Pfizer Worldwide Research and Development, Groton, Connecticut, USA
| | | | | | | | | | | | | | | |
Collapse
|
47
|
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.
Collapse
|
48
|
Cutaneous necrosis as a presenting manifestation of antiphospholipid antibodies. J Clin Rheumatol 2011; 17:446-8. [PMID: 22089989 DOI: 10.1097/rhu.0b013e31823b0fd9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|