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Younger DS. Headaches and Vasculitis. Neurol Clin 2024; 42:389-432. [PMID: 38575258 DOI: 10.1016/j.ncl.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Vasculitis refers to heterogeneous clinicopathologic disorders that share the histopathology of inflammation of blood vessels. Unrecognized and therefore untreated, vasculitis of the nervous system leads to pervasive injury and disability making this a disorder of paramount importance to all clinicians. Headache may be an important clue to vasculitic involvement of central nervous system (CNS) vessels. CNS vasculitis may be primary, in which only intracranial vessels are involved in the inflammatory process, or secondary to another known disorder with overlapping systemic involvement. Primary neurologic vasculitides can be diagnosed with assurance after intensive evaluation that incudes tissue confirmation whenever possible.
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Affiliation(s)
- David S Younger
- Department of Medicine, Section of Neuroscience, City University of New York School of Medicine, New York, NY, USA; Department of Neurology, White Plains Hospital, White Plains, NY, USA.
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Abstract
PURPOSE OF REVIEW Drug-induced vasculitis (DIV) is a rare form of vasculitis related to the use of various drugs. DIV primarily affects small to medium size vessels, but it can potentially involve vessels of any size. Differentiating between primary systemic vasculitis and DIV can be challenging; however, it is crucial, so that the offending agent can be discontinued promptly. RECENT FINDINGS The clinical phenotype of DIV is protean and depends on the size of the affected vessels. It ranges from arthralgias, to an isolated cutaneous rash, to severe single or multi-organ involvement. While withdrawal of the offending drug is the most important step in management, a significant number of patients require immunosuppressive therapy for varying periods of time. DIV can affect any vascular bed size, leading to protean vasculitic syndromes. Increased awareness among general practitioners, specialty, and subspecialty physicians is crucial for early recognition, and withdrawal of drug for better outcomes.
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Brust JC. Stroke and Substance Abuse. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00039-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Scolding N. CNS involvement in systemic vasculitides. J Neurol Sci 2021; 424:117423. [PMID: 33840508 DOI: 10.1016/j.jns.2021.117423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/26/2021] [Accepted: 03/24/2021] [Indexed: 11/16/2022]
Abstract
Both the CNS and the PNS can be involved in almost all of the vasculitides - including the primary systemic vasculitic disorders, such as microscopic polyangiitis and polyarteritis nodosa, and in non-vasculitic systemic disorders, such as systemic lupus erythematosis and sarcoidosis. The latter diseases also include infections and toxininduced disorders - particularly drugs of abuse such as cocaine and amphetamines. Here we will summarise the spectrum of these disorders as they affect the CNS, concentrating in particular on their distinguishing clinical and investigational features.
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Affiliation(s)
- Neil Scolding
- Burden Professor of Clinical Neurosciences, University of Bristol Institute of Clinical Neurosciences, UK, Gulu University Faculty of Medicine, Uganda.
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Younger DS. Cerebral vasculitis associated with drug abuse. Curr Opin Rheumatol 2021; 33:24-33. [PMID: 33186242 DOI: 10.1097/bor.0000000000000766] [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: 11/25/2022]
Abstract
PURPOSE OF REVIEW To review understand the epidemiology, background, neuropharmacology, and histopathology of literature verified cases, and likely etiopathogenic mechanisms. RECENT FINDINGS There are only a handful of histologically confirmed patients in the literature with cerebral vasculitis because of drug abuse. SUMMARY There is little justification for invasive laboratory investigation given the ready availability of highly accurate vascular neuroimaging techniques to dictate management, which usually rests upon avoidance of further exposure and minimizing the secondary neurotoxic effects of the abused substances and polypharmacy use.
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Affiliation(s)
- David S Younger
- City University of New York Medical School, New York, New York, USA
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Abstract
Illicit drug abuse is a common differential diagnosis of acquired central nervous system vasculitis even though there are only a handful of histopathologically confirmed patients in the literature from among the many potential classes of abused drugs traditionally implicated in this disease. This article considers the major classes of illicit drugs in those with and without human immunodeficiency virus type-1 infection and acquired immune deficiency syndrome.
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Affiliation(s)
- David S Younger
- Department of Neurology, Division of Neuro-Epidemiology, New York University School of Medicine, New York, NY, USA; School of Public Health, City University of New York, New York, NY, USA.
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Shvartsbeyn M, Phillips DGK, Markey MA, Morrison A, DeJong JL, Castellani RJ. Cocaine-induced intracerebral hemorrhage in a patient with cerebral amyloid angiopathy. J Forensic Sci 2011; 55:1389-92. [PMID: 20456585 DOI: 10.1111/j.1556-4029.2010.01410.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Intracerebral hemorrhage (ICH) is a well-recognized complication of recreational cocaine use. The precise mechanism of the cocaine-induced hemorrhagic event is unclear, although multiple factors have been implicated. We report a case of a 62-year-old woman who suffered left parieto-occipital ICH with herniation and death, following a cocaine binge. Microscopic examination also revealed extensive cerebral amyloid angiopathy (CAA) in the vicinity of the hemorrhage. We additionally studied brain tissue in eight subjects between ages of 60 and 80 who were positive for cocaine metabolites at autopsy; of these, none had vascular amyloid-β deposits by immunohistochemistry. Whereas we found no evidence that chronic cocaine use is a risk factor for CAA, given the age-associated nature of CAA and the aging population using cocaine, CAA-induced hemorrhage in the setting of cocaine use may be more common than recognized. This is the first reported case of CAA-associated ICH precipitated by cocaine.
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Affiliation(s)
- Marianna Shvartsbeyn
- Department of Pathology, New York University School of Medicine, New York, NY, USA
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Stroke and Substance Abuse. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10042-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Bhattacharya P, Taraman S, Shankar L, Chaturvedi S, Madhavan R. Clinical profiles, complications, and disability in cocaine-related ischemic stroke. J Stroke Cerebrovasc Dis 2010; 20:443-9. [PMID: 20813550 DOI: 10.1016/j.jstrokecerebrovasdis.2010.02.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2009] [Revised: 01/03/2010] [Accepted: 02/05/2010] [Indexed: 10/19/2022] Open
Abstract
Cocaine use is associated with ischemic stroke through unique mechanisms, including reversible vasospasm, drug-induced arteritis, enhanced platelet aggregation, cardioembolism, and hypertensive surges. To date, no study has described disability in patients with cocaine-related ischemic stroke. The present study compared risk factors, comorbidities, complications, laboratory findings, medications, and outcomes in patients with cocaine-related (n = 41) and non-cocaine-related (n = 221) ischemic stroke (n = 147) and transient ischemic attack (n = 115) in 3 academic hospitals. The patients with cocaine-related stroke were younger (mean age, 51.9 years vs 59.1 years; P = .0008) and more likely to be smokers (95% vs 62.9%; P < .004). The prevalence of arrhythmias was significantly higher in the patients with cocaine-related stroke, and that of diabetes was significantly higher in those with non-cocaine-related strokes. The prevalence of hypertension and lipid profiles were similar in the 2 groups; however, those with cocaine-related stroke were less likely to receive statins. Antiplatelet use was similar in the 2 groups. Survivors of both groups had similar modified Rankin scores and lengths of hospital stay. In the older urban population, smoking and cocaine use may coexist with other cerebrovascular risk factors, and cocaine-related strokes have similar morbidities and mortality as non-cocaine-related strokes. Moreover, because the patients with cocaine-related stroke is younger, they have an earlier morbidity. New strategies for effective stroke prevention interventions are needed in this subgroup.
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Affiliation(s)
- Nicole M Orzechowski
- Mayo School of Graduate Medical Education, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA
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Nanda A, Vannemreddy P, Willis B, Kelley R. Stroke in the young: relationship of active cocaine use with stroke mechanism and outcome. ACTA NEUROCHIRURGICA. SUPPLEMENT 2006; 96:91-6. [PMID: 16671433 DOI: 10.1007/3-211-30714-1_22] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Cocaine and other vasoactive substances are known causes of cerebrovascular disease. Ictus during drug intake adversely affects outcome. MATERIALS AND METHODS A retrospective review revealed 42 patients with cocaine abuse and stroke. Aneurysmal bleed occurred in 15 patients; the rest had stroke. The outcome of stroke because of cocaine intoxication was analyzed. RESULTS Mean age for stroke was 38 (+/- 8.5 SD) years; males out-numbered females (20 : 7) similar to the pattern seen in subarachnoid hemorrhage (SAH) following aneurysm rupture. Nine had intracerebral hematomas, 6 had SAH with intracerebral hemorrhage (ICH)/ infarct, I had transverse myelopathy. Transient ischemic attack was identified in 4. Carotid occlusion was found in 2, and slow-flow in the vertebrobasilar system in 1. Fifteen were known hypertensives. Cocaine was the principal substance in all patients; 7 used other substances including marijuana and heroin. Three patients had HIV, 3 had hepatitis, 2 had syphilis, and 1 had tuberculosis. Urinalysis was positive for cocaine metabolites in 15; 2 had late analysis. Nine had ICH or SAH with poor neurological status at admission and died. Cocaine intoxication correlated with fatal cerebrovascular accident (CVA) (p < 0.001) and poor Glasgow Outcome Score (GOS) (p < 0.001). CONCLUSION Stroke and cocaine use correlated with fatal CVA and poor outcome. Prompt diagnostic intervention may reveal the incidence of CNS injury with cocaine abuse.
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Affiliation(s)
- A Nanda
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA 71130, USA
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Tacker DH, Okorodudu AO. Evidence for injurious effect of cocaethylene in human microvascular endothelial cells. Clin Chim Acta 2004; 345:69-77. [PMID: 15193979 DOI: 10.1016/j.cccn.2004.02.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2003] [Revised: 02/26/2004] [Accepted: 02/26/2004] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cocaethylene (CE) is a conjugate of cocaine and ethanol that may contribute to the pathogenesis of systemic vascular diseases. This study was conducted to investigate the effect of CE on human microvascular endothelial cells (HMEC-1) in culture. METHODS Proliferating and confluent monolayers of HMEC-1 were used for assessing growth kinetics, viability, cytotoxicity, and morphologic/barrier alterations after CE treatment (0-1 mmol/l) for up to 7 days. The Trypan blue exclusion, lactate dehydrogenase (LDH) release assay, manual cell counts, and silver nitrate staining technique were used. RESULTS The doubling times of 30.0 and 31.4 h for the 0.5 and 1.0 mmol/l CE-treated HMEC-1, respectively, were significantly longer than the 28.6 h for the control group (p < 0.05). The viabilities of 90.4 +/- 3.8% (control) and 93.1 +/- 1.9% (CE-treated) from the Trypan blue exclusion-staining experiments indicated non-lethality of CE. LDH activities of 173 +/- 33 U/l (control) and 157 +/- 43 U/l (CE-treated) confirmed the absence of CE cytotoxicity. Silver staining results indicated increased monolayer permeability as demonstrated by the formation of intercellular gaps after 1 h of exposure. CONCLUSIONS HMEC-1 exposure to CE induced cellular injury that could affect the permeability of small blood vessels. These cellular changes could in part be the pivotal point for studies to explain the edema and inflammation in surrounding tissues of individuals exposed to CE.
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Affiliation(s)
- Danyel Hermes Tacker
- Division of Clinical Chemistry, Department of Pathology, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0551, USA
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Büttner A, Weis S. Central Nervous System Alterations in Drug Abuse. FORENSIC PATHOLOGY REVIEWS 2004. [DOI: 10.1007/978-1-59259-786-4_4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Hajj-Ali RA, Ghamande S, Calabrese LH, Arroliga AC. Central nervous system vasculitis in the intensive care unit. Crit Care Clin 2002; 18:897-914. [PMID: 12418446 DOI: 10.1016/s0749-0704(02)00027-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Intensivists are sometimes faced with unexplained neurologic defects in ICU patients. A subacute presentation over weeks or months characterized by headache and mental status change with focal deficits in the absence of evidence of secondary vasculitis or other diseases mentioned in the differential diagnosis should arouse suspicion of PACNS. Delay in diagnosis of this rare condition may lead to additional morbidity and prolong ICU stay. There is also a risk of permanent cognitive dysfunction with untreated PACNS. A reactive CSF picture, ischemic changes on MR imaging, and alterations in vessel caliber on cerebral angiography are not diagnostic but strengthen the evidence for PACNS. A brain biopsy may be required to confirm the diagnosis. High-dose steroid therapy with a prolonged course and gradual taper controls the disease in most cases. Additional immunosuppressive therapy is needed in some patients.
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Affiliation(s)
- Rula A Hajj-Ali
- Department of Internal Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue-G62, Cleveland, OH 44195, USA
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Barroso-Moguel R, Mendez-Armenta M, Villeda-Hernandez J, Nava-Ruiz C, Santamaria A. Brain lesions induced by chronic cocaine administration to rats. Prog Neuropsychopharmacol Biol Psychiatry 2002; 26:59-63. [PMID: 11853120 DOI: 10.1016/s0278-5846(01)00229-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Cocaine is a common drug of abuse, and its use has emerged as a major public health problem with neurological complications. In this work, the authors studied microscopic lesions produced in brain by chronic cocaine administration to rats. Twenty-five Wistar rats were exposed to 30 mg/kg/day ip of cocaine and sacrificed at 15, 30, 45, 60, and 90 days after treatment and compared to 25 control rats injected daily with saline. The parietal cortex (Cx), hippocampus (Hp), substantia nigra (SN), and cerebellum (Ce) were morphologically analyzed. The authors found progressive light microscopic lesions in all regions studied, including nuclear pyknosis and atrophy, interstitial edema, broken fibers, and necrosis. Results show that chronic treatment with cocaine in rats leads to selective severe lesions in different brain regions.
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Affiliation(s)
- Rosario Barroso-Moguel
- Laboratory of Cellular Neuromorphology, National Institute of Neurology and Neurosurgery, Manuel Velasco Suárez, Mexico City, Mexico
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Trimarchi M, Gregorini G, Facchetti F, Morassi ML, Manfredini C, Maroldi R, Nicolai P, Russell KA, McDonald TJ, Specks U. Cocaine-induced midline destructive lesions: clinical, radiographic, histopathologic, and serologic features and their differentiation from Wegener granulomatosis. Medicine (Baltimore) 2001; 80:391-404. [PMID: 11704715 DOI: 10.1097/00005792-200111000-00005] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- M Trimarchi
- Department of Otorhinolaryngology, University of Brescia, Italy
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Abstract
DIV is a relatively common cause of inflammatory vasculitis. Drugs from almost every pharmacologic class have been implicated in causing vasculitis in sporadic cases. The level of certainty and quality of evidence for these associations between specific agents and vasculitis vary greatly. The clinical manifestations of DIV range from single organ involvement (most commonly, skin) to life-threatening multiorgan disease. The recently described subset of cases of DIV associated with positive tests for ANCA are an interesting subset of DIV. The diagnosis of DIV is usually one of exclusion. The treatment of DIV is dependent on the severity of disease activity but should always include withdrawal of the suspected drug. If no agent can be implicated, as many drugs as feasible should be discontinued. The necessity of prescribing glucocorticoids or immunosuppressive agents depends on the disease severity and other case-specific information. Increasing understanding of the pathophysiologic characteristics of all inflammatory vasculitides should lead to better diagnostic and therapeutic approaches to DIV.
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Affiliation(s)
- P A Merkel
- Arthritis Center, Boston University School of Medicine, and Rheumatology Section, Boston University Medical Center, Boston, Massachusetts, USA.
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Del Rosso A, Generini S, Pignone A, Matucci-Cerinic M. Vasculitides secondary to systemic diseases. Clin Dermatol 1999; 17:533-47. [PMID: 10590846 DOI: 10.1016/s0738-081x(99)00060-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- A Del Rosso
- Department of Medicine, University of Florence, Italy
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Abstract
A case of massive intracerebral hemorrhage, a rare but often fatal complication of amphetamine abuse, is described along with the review of the literature. There has been resurgence in the abuse of amphetamine. Amphetamine or other illicit drug abuse should be considered in young patients with cerebrovascular events.
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Affiliation(s)
- C Chaudhuri
- Department of Medicine, University of Mississippi Medical Center, Jackson 39216-4505, USA
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Abstract
This article is an introduction to the historical background, clinical and laboratory diagnosis, pathogenesis, and treatment of vasculitis involving the peripheral and central nervous system. It also provides a background for the articles that follow.
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Affiliation(s)
- D S Younger
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, New York 10021, USA
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Wynne PJ, Younger DS, Khandji A, Silver AJ. Radiographic features of central nervous system vasculitis. Neurol Clin 1997; 15:779-804. [PMID: 9367964 DOI: 10.1016/s0733-8619(05)70347-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Central nervous system (CNS) vasculitis refers to primary and secondary disorders of the CNS vasculature. Most authorities agree that CNS vasculitis is a potentially serious disorder; therefore, prompt diagnosis and initiation of therapy are high priorities in treatment. Remarkable progress has been made in the diagnosis, evaluation, and treatment of this disorder. This article examines many aspects of the radiographic evaluation of CNS vasculitis.
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Affiliation(s)
- P J Wynne
- Department of Radiology, Division of Neuroradiology, Columbia-Presbyterian Medical Center, New York, New York 10032, USA
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Abstract
The term drug dependence refers to psychic dependence (addiction), physical dependence, or both, in someone who administers a drug periodically or continuously. Recreational drug abusers are at risk for occlusive and hemorrhagic stroke of diverse cause. Although sometimes over diagnosed, cerebral vasculitis has been historically verified in users of legal and illegal drugs.
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Affiliation(s)
- J C Brust
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, New York, USA
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Barroso-Moguel R, Villeda-Hernández J, Méndez-Armenta M, Ríos C. Brain capillary lesions produced by cocaine in rats. Toxicol Lett 1997; 92:9-14. [PMID: 9242352 DOI: 10.1016/s0378-4274(97)00027-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In the last 20 years, acute and chronic cocaine addiction has increased among young and adult people. The effects of cocaine on brain vasculature of young animals have not been histologically studied in depth. In the present study, we report the lesions of brain capillaries, including the choroid plexus, produced by chronic cocaine administration, in adult Wistar rats receiving i.p., 30 mg/kg/day of aqueous cocaine hydrochloride solution. Rats were sacrificed after several days of treatment. Histopathological examination of capillaries from different brain regions and cerebellum was performed using light microscopy. At 7 days, there were initial signs of dilatation, rupture and thrombosis of capillaries. At 15 days of treatment small interstitial oedema and hemorrhages by rupture of the basal membrane of the capillaries was found. At 30 days of treatment, many capillaries from different areas showed fibroid endothelial thickening, and wall fibrosis become evident after 60 days of daily cocaine. In numerous places (cortex, gray nucleus: thalamus, caudate, hippocampus and cerebellum) we observed capillaries with an occluded lumen probably due to fibrosis or thrombi after 90 days of treatment. In the latter treatment, capillaries from the choroid plexuses had their lumen dilated and the epithelial cells vacuolated or necrotic. We hypothesize that the chronic administration of cocaine in rats induced brain lesions in part as a result of capillary disruption and subsequent extravasation of erythrocytes to brain parenchyma.
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Affiliation(s)
- R Barroso-Moguel
- Laboratorio de Neuromorfología Celular, Instituto Nacional de Neurología y Neurocirugía MVS, México D.F
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Abstract
Cocaine use is associated with a variety of serious neurological complications, including cerebral infarction, intracerebral and subarachnoid hemorrhage, transient ischemic attacks, migraines, and seizures. We report two cases of intracerebral hemorrhage with biopsy-proven cerebral vasculitis associated with the use of cocaine. The first case involved a 32-year-old man who presented with headache, left-sided hemiparesis, and severe hypertension and who was found to have a large right putaminal hemorrhage on cranial tomographic (CT) scan. Cerebral angiography did not show vasculitic changes, but brain tissue obtained during hematoma evacuation revealed a nonnecrotizing leukocytoclastic angiitis of the small vessels. The second case involved a 20-year-old man who presented with headache, agitation, and speech difficulty that progressed to disorientation and dysphasia. He had a large left temporoparietal hematoma seen on CT scan. Cerebral angiography was consistent with vasculitis, and brain tissue obtained during hematoma evacuation revealed a small vessel vasculitis. In both cases, thorough clinical and laboratory investigations found no evidence of systemic vasculitis or an etiologic agent other than cocaine. We also critically reviewed the previously reported cases of cocaine-associated cerebral vasculitis and the relevant medical literature to discuss the "cocaine-associated vasculitis syndrome" in the context of more established vasculitidies, including hypersensitivity vasculitis. In addition, we outline a diagnostic and therapeutic approach to patients with possible cocaine-associated vasculitis.
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Affiliation(s)
- P A Merkel
- Department of Medicine, Massachusetts General Hospital, Boston, 02114, USA
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