Cocaine/Levamisole-Induced, Skin-Limited ANCA-Associated Vasculitis with Pyoderma Gangrenosum-like Presentation

The use of levamisole as the most frequent adulterant of cocaine has merged in previously unknown toxicities, notably a disease entity called cocaine/levamisole-associated autoimmune syndrome (CLAAS). Clinically, CLAAS can manifest with diverse cutaneous and extracutaneous features sharing common laboratory findings (neutropenia, autoantibody patterns). We report the case of a cocaine-abusing female patient with relapsing episodes of painful ulcers, worsening and expanding over a three-year period. The case exhibited all features of a drug-induced, skin-limited, ANCA-associated vasculitis, evolving over time to PG-like findings. In both disease stages, the patient responded well to the cessation of cocaine exposure and systemic glucocorticosteroids. This case demonstrates the continuous nature of cutaneous CLAAS manifestations in a single patient. CLAAS has become a major public health issue in the at-risk group of cocaine users, and clinicians should be alert of this condition when treating cocaine users presenting with single or multiple skin ulcerations.

COVID-19 infection and treatment-resistant cocaine-induced pyoderma gangrenosum: A case report

Introduction

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis of non-infectious etiology. Cocaine-induced PG (CIPG) is a documented clinical variant.

Case presentation

We report an exceptional case of cocaine-induced PG flare unresponsive to conventional treatment in the context of positive COVID status. A 41year-old male with past medical history of recent COVID infection, pyoderma gangrenosum and chronic cocaine abuse presented with acutely worsening multifocal ulcerations covering multiple limbs approximately 30% body surface area (BSA) one day after cocaine use. After hospitalization for ten days with no improvement in cutaneous symptoms, he was transferred to a burn center for disease control with biologics.

Discussion

The previous temporal relationship between disease outbreak and cocaine consumption and improvement after its discontinuation no longer remained in the setting of COVID positive status. This is the first case in literature of extensive and treatment-refractory PG in a COVID-positive patient with recent cocaine use.

Conclusion

This case highlights the importance of further investigation on the connection between COVID infection and PG and the need for establishing treatment guidelines for PG.

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This is the first recorded case of treatment-refractory cocaine-induced pyoderma gangrenosum with active COVID infection.

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Further studies on the relationship between active COVID infection and Pyoderma Gangrenosum exacerbations are warranted.

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Multidisciplinary care is needed in tailoring management to persistent pyoderma gangrenosum in patients with COVID infection.

Neutrophilic dermatosis of the dorsal hands related to cocaine abuse

Neutrophilic dermatoses encompass a wide spectrum of diseases characterized by a dense infiltration mainly composed of neutrophils. Neutrophilic dermatosis of the dorsal hands is currently considered a localized variant of Sweet syndrome. Cocaine abuse has been related to a wide range of mucocutaneous manifestations, including neutrophilic dermatoses such as pyoderma gangrenosum. The authors of this study present a patient with neutrophilic dermatosis of the dorsal hands, in which cocaine abuse was identified as a probable trigger.

Pyoderma gangrenosum associated to the use of cocaine/levamisole. Series of three cases and literature review

Pyoderma gangrenosum associated to the use of cocaine/levamisole is a rare condition associated to their consumption. Cocaine use is frequent in Colombia, and the substance is contaminated with levamisole, an anthelmintic that increases the psychotropic effects and enhances its side effects. We present three clinical cases of patients with ulcerated lesions, in which the diagnosis was pyoderma gangrenosum secondary to the use of cocaine contaminated with levamisole. This called the attention of the health staff to investigate the abuse of substances in gangrenous pyoderma and also evidence that the interruption of consumption was the basis of management.

Acne in the first three decades of life: An update of a disorder with profound implications for all decades of life

Acne vulgaris is a chronic, inflammatory, skin condition that involves the pilosebaceous follicles and is influenced by a variety of factors including genetics, androgen-stimulation of sebaceous glands with abnormal keratinization, colonization with Cutibacterium acnes (previously called Propionibacterium acnes), and pathological immune response to inflammation. Acne can occur at all ages and this discussion focuses on the first three decades of life. Conditions that are part of the differential diagnosis and/or are co-morbid with acne vulgaris are also considered. Acne in the first year of life includes neonatal acne (acne neonatorum) that presents in the first four weeks of life and infantile acne that usually presents between 3 and 6 months of the first year of life with a range of 3 to 16 months after birth. Acne rosacea is a chronic, inflammatory, skin condition that is distinct from acne vulgaris, typically presents in adults, and has four main types: erythemato-telangiectatic, papulopustular, phymatous and ocular. Treatment options for acne vulgaris include topical retinoids, topical benzoyl peroxide, antibiotics (topical, oral), oral contraceptive pills, isotretinoin, and others. Management must consider the increasing impact of antibiotic resistance in the 21st century. Psychological impact of acne can be quite severe and treatment of acne includes awareness of the potential emotional toll this disease may bring to the person with acne as well as assiduous attention to known side effects of various anti-acne medications (topical and systemic). Efforts should be directed at preventing acne-caused scars and depigmentation on the skin as well as emotional scars within the person suffering from acne.

Multifocal cocaine-induced pyoderma gangrenosum: A report of two cases and review of literature

Pyoderma gangrenosum is often associated with a systemic disease. Cocaine-induced pyoderma gangrenosum, most probably caused by levamisole, has been described recently and typically presents as multiple, large cribriform ulcers. Peri-nuclear antineutrophil cytoplasmic antibody is the most common serological finding. A strong counseling for cocaine cessation, combined with wound care and immunosuppressive therapy, is the mainstay of treatment. We present two cases of cocaine-induced pyoderma gangrenosum and correlate their findings with the typical clinical, histological and serological presentation.

Applying Intravenous Immunoglobulin and Negative-Pressure Wound Therapy to Treat Refractory Pyoderma Gangrenosum: A Case Report

Pyoderma gangrenosum (PG) is a rare chronic neutrophilic dermatosis that causes undermining ulcers. Unfortunately, standardization of PG treatment remains a challenge. In this article, we describe a case in which a 69-year-old man presented with a painful ulcer on the right lower leg. The diagnosis of PG was made after excluding other diseases. He had a history of PG on his left lower leg 2 years earlier and was cured by the treatment of systemic corticosteroids and cyclosporin A for 43 days. However, such a treatment was not effective this time. Hence, we applied intravenous immunoglobulin and negative-pressure wound therapy, and the patient was cured. Altogether, this case supports the use of intravenous immunoglobulin as an effective adjuvant for refractory PG, and indicates negative-pressure wound therapy as a treatment option to advance ulcer healing under adequate immunosuppression.

Pyoderma gangrenosum and tumour necrosis factor alpha inhibitors: A semi-systematic review

Pyoderma gangrenosum (PG) is a rare ulcerative skin disease that presents a therapeutic challenge. Tumour necrosis factor alpha (TNFα) inhibitors have been reported to successfully control PG. Our aim was to systematically evaluate and compare the clinical effectiveness of TNFα inhibitors in adults with PG. A literature search including databases such as PubMed, Embase, Scopus, and Web of Science was conducted, using search terms related to PG and TNFα inhibitors. Studies and case reports were included if patients were diagnosed with PG, over the age of 18 and administered TNFα inhibitor. A total of 3212 unique citations were identified resulting in 222 articles describing 356 patients being included in our study. The study we report found an 87% (95% CI: 83%-90%) response rate and a 67% (95% CI: 62%-72%) complete response rate to TNFα inhibitors. No statistically significant differences in the response rates (P = 0.6159) or complete response rates (P = 0.0773) to infliximab, adalimumab, and etanercept were found. In our study TNFα inhibitors demonstrated significant effectiveness with response and complete response rates supporting the use of TNFα inhibitors to treat PG in adults. Our study suggests that there is no significant difference in effectiveness among infliximab, adalimumab, and etanercept.

Biologic and small-molecule medications in the management of pyoderma gangrenosum

Pyoderma gangrenosum (PG) is an uncommon inflammatory skin disorder characterized by neutrophil dysfunction. There are currently no FDA-approved drugs for the treatment of this disease, and treatment has typically relied on traditional immunosuppressive medications such as prednisone or cyclosporine. The efficacy of biologics in the treatment of other pro-inflammatory conditions such as psoriasis, rheumatoid arthritis, and inflammatory bowel disease is well-documented in the literature. Therefore, the use of biologic medications for the treatment of rarer inflammatory skin conditions, such as PG, is a compelling topic for investigation. Biologic and small-molecule therapies allow physicians to target specific pro-inflammatory mediators that underlie PG pathogenesis. This review provides an update on the use of biologic and small-molecule medications for the treatment of PG and summarizes the latest data on the clinical efficacy and pharmacology of these treatments.

Drug-Induced Pyoderma Gangrenosum: A Review

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that may be caused by an adverse drug reaction. We discuss the clinical presentation and outcomes of 52 cases of drug-induced PG reported to date in the literature. We conducted our literature search for case reports of drug-induced PG using keywords on PubMed and Medical Subject Heading (MeSH) terms on MEDLINE and EMBASE. To assess the probability that each case of PG was related to drug therapy, we used the Naranjo criteria. We identified 44 studies in the literature, with a total of 52 cases of drug-induced PG. The mean Naranjo score for cocaine-induced PG (n = 13) was 9.4, indicating a definite adverse drug reaction, while the mean Naranjo scores for isotretinoin (n = 5), propylthiouracil (n = 5), and sunitinib (n = 5) were 6.2, 6.8, and 7.4, respectively, indicating probable adverse drug reactions. Drugs should be considered as a possible triggering event whenever PG is diagnosed, and clinicians should particularly consider this in patients taking isotretinoin, propylthiouracil, or sunitinib, as well as in patients with a history of cocaine use.

Pyoderma Gangrenosum: A Current Problem as Much as an Unknown One

Pyoderma gangrenosum (PG) is a rare neutrophilic inflammatory skin disease, characterized by recurrent skin ulcers, which in almost 50% of cases are associated with systemic autoimmune disorders, including rheumatoid arthritis, chronic hepatitis, inflammatory bowel disease, paraproteinemias and hematological malignancies. A systematic search of literature for PG was carried out using the PubMed, Embase, and Google Scholar databases for the purpose of this review and 2780 articles were retrieved up to February 2017. Inflammation represents the predominant aspect of the disease, but its pathophysiological mechanisms are not completely clear yet, since there are many studies showing only one or more isolated findings of the disease. The goal of PG treatment is to reduce inflammation in order to promote ulcer healing by minimizing side effects of therapy. Several systemic and local treatments are available, but the lack of large randomized double-blind studies results in an absence of a uniform therapeutic standard: thus, more clinical studies are required in order to make head-to-head comparisons between combination and single-drug therapies and to identify specific combination therapies for distinctive clinical patterns of PG.