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Guerra-Ojeda S, Marchio P, Suarez A, Aldasoro M, Valles SL, Genoves P, Vila JM, Mauricio MD. Levamisole Impairs Vascular Function by Blocking α-Adrenergic Receptors and Reducing NO Bioavailability in Rabbit Renal Artery. Cardiovasc Toxicol 2024; 24:789-799. [PMID: 38877381 PMCID: PMC11300484 DOI: 10.1007/s12012-024-09879-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 06/04/2024] [Indexed: 06/16/2024]
Abstract
Levamisole is an anthelmintic drug restricted to veterinary use but is currently detected as the most widely used cocaine cutting agent in European countries. Levamisole-adulterated cocaine has been linked to acute kidney injury, marked by a decrease in glomerular filtration rate, which involves reduced renal blood flow, but data on the alteration of renovascular response produced by levamisole are scarce. Renal arteries were isolated from healthy rabbits and used for isometric tension recording in organ baths and protein analysis. We provide evidence that depending on its concentration, levamisole modulates renovascular tone by acting as a non-selective α-adrenergic receptor blocker and down-regulates α1-adrenoceptor expression. Furthermore, levamisole impairs the endothelium-dependent relaxation induced by acetylcholine without modifying endothelial nitric oxide synthase (eNOS) expression. However, exposure to superoxide dismutase (SOD) partially prevents the impairment of ACh-induced relaxation by levamisole. This response is consistent with a down-regulation of SOD1 and an up-regulation of NADPH oxidase 4 (Nox4), suggesting that endothelial NO loss is due to increased local oxidative stress. Our findings demonstrate that levamisole can interfere with renal blood flow and the coordinated response to a vasodilator stimulus, which could worsen the deleterious consequences of cocaine use.
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Affiliation(s)
- Sol Guerra-Ojeda
- Department of Physiology, School of Medicine, University of Valencia, Blasco Ibañez, 15, 46010, Valencia, Spain
- INCLIVA, Institute of Health Research, Valencia, Spain
| | - Patricia Marchio
- Department of Physiology, School of Medicine, University of Valencia, Blasco Ibañez, 15, 46010, Valencia, Spain
| | - Andrea Suarez
- Department of Physiology, School of Medicine, University of Valencia, Blasco Ibañez, 15, 46010, Valencia, Spain
- INCLIVA, Institute of Health Research, Valencia, Spain
| | - Martin Aldasoro
- Department of Physiology, School of Medicine, University of Valencia, Blasco Ibañez, 15, 46010, Valencia, Spain
- INCLIVA, Institute of Health Research, Valencia, Spain
| | - Soraya L Valles
- Department of Physiology, School of Medicine, University of Valencia, Blasco Ibañez, 15, 46010, Valencia, Spain
| | - Patricia Genoves
- Department of Physiology, School of Medicine, University of Valencia, Blasco Ibañez, 15, 46010, Valencia, Spain
- INCLIVA, Institute of Health Research, Valencia, Spain
- Center for Biomedical Research Network on Cardiovascular Diseases (CIBER-CV), Madrid, Spain
| | - Jose M Vila
- Department of Physiology, School of Medicine, University of Valencia, Blasco Ibañez, 15, 46010, Valencia, Spain
- INCLIVA, Institute of Health Research, Valencia, Spain
| | - Maria D Mauricio
- Department of Physiology, School of Medicine, University of Valencia, Blasco Ibañez, 15, 46010, Valencia, Spain.
- INCLIVA, Institute of Health Research, Valencia, Spain.
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Thijs E, Hurley D, Cummings B, Elewaut D, Verougstraete N, Claerhout I, Murphy CC, Power W, Roels D. Levamisole-Adulterated Cocaine-Induced Mucous Membrane Pemphigoid: Case Reports and Literature Review. Cornea 2024; 43:1053-1057. [PMID: 38294898 DOI: 10.1097/ico.0000000000003481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/14/2023] [Indexed: 02/02/2024]
Abstract
PURPOSE The aim of this study was to report 2 cases of levamisole-adulterated cocaine-induced mucous membrane pemphigoid. METHODS This study is a review of case reports and literature. RESULTS Two patients presented with bilateral severe purulent conjunctivitis, corneal ulceration, and rapidly progressive forniceal shortening. Both patients were active cocaine users. A complete blood analysis showed a positive antineutrophil cytoplasmic antibody immunofluorescence with a mixed perinuclear antineutrophil cytoplasmic antibody and cytoplasmic-staining antineutrophil cytoplasmic antibody pattern. Direct immunofluorescence examination of conjunctival tissue showed linear deposition of component 3 and immunoglobulins at the basal membrane. A diagnosis of levamisole-adulterated cocaine-induced mucous membrane pemphigoid was made. In case 1, this suspicion was confirmed by investigating remnants of cocaine on the patient's debit card using mass spectrometry, which contained traces of levamisole. In both cases, aggressive immunosuppressive therapy combining systemic corticosteroids and rituximab was able to control the disease. However, by the time these therapies were initiated, significant corneal injury had occurred requiring corneal grafts in both patients. CONCLUSIONS Given the rising abuse of cocaine, it is important that ophthalmologists are made aware of its association with severe atypical cicatricial conjunctivitis. To the best of our knowledge, we present the first case proving the causal relationship between levamisole and ocular cicatricial pemphigoid.
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Affiliation(s)
- Elke Thijs
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Daire Hurley
- Department of Ophthalmology, Royal Victoria Eye and Ear Hospital, Dublin, Ireland
| | - Brendan Cummings
- Department of Ophthalmology, Royal Victoria Eye and Ear Hospital, Dublin, Ireland
| | - Dirk Elewaut
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Nick Verougstraete
- Department of Clinical Chemistry, Ghent University Hospital, Ghent, Belgium
| | - Ilse Claerhout
- Department of Ophthalmology, AZ Maria Middelares Hospital, Ghent, Belgium ; and
| | - Conor C Murphy
- Department of Ophthalmology, Royal Victoria Eye and Ear Hospital, Dublin, Ireland
| | - William Power
- Department of Ophthalmology, Royal Victoria Eye and Ear Hospital, Dublin, Ireland
| | - Dimitri Roels
- Department of Ophthalmology, Ghent University Hospital, Ghent, Belgium
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Sinha R, Sarkar S, Banerjee S, Akhtar S, Poddar S, Dasgupta D, Saha R, Sengupta J, Mandal M, Tse Y, Pahari A. Antineutrophil cytoplasmic antibody in children with nephrotic syndrome treated with levamisole: a cross-sectional cohort study. Pediatr Nephrol 2024; 39:2423-2427. [PMID: 38589697 DOI: 10.1007/s00467-024-06362-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 03/10/2024] [Accepted: 03/11/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Levamisole is a commonly used steroid-sparing agent (SSA), but the reported incidence of antineutrophil cytoplasmic antibody (ANCA) positivity has been concerning. METHODS Observational cross-sectional study wherein children aged 2 to 18 years with frequently relapsing/steroid dependent nephrotic syndrome (FRNS/SDNS) on levamisole for ≥ 12 months were tested for ANCA. RESULTS A total of 210 children (33% female), median age of 7.3 (IQR: 5.6-9.6) years, and a median duration of levamisole exposure of 21 (IQR: 15-30) months were tested. ANCA was positive in 18% (n = 37): 89% (n = 33) perinuclear ANCA (pANCA), 3% (n = 1) cytoplasmic ANCA (cANCA), and 8% (n = 3) both. Of ANCA-positive children, none had reduced eGFR or abnormal urinalysis. The majority of these children were asymptomatic (81%, n = 30). Rash was more common among ANCA-positive children [6/37 (16%) vs. 3/173 (2%), p = 0.0001]. On multivariate analysis, higher age (OR = 1.02, [95th CI: 1.01 to 1.03], p = 0.007) and longer duration of levamisole exposure (OR = 1.05, [95th CI: 1.02 to 1.08], p = 0.0007) were associated with ANCA positivity. Levamisole was stopped in ANCA-positive children with the resolution of any clinical manifestations if present. Repeat ANCA testing was performed in 54% (20/37), and all were ANCA negative by 18 months. CONCLUSIONS Children with FRNS/SDNS on longer duration of levamisole were associated with increasing prevalence of ANCA positivity, but most of these children were clinically asymptomatic. Prospective studies are required to determine the chronology of ANCA positivity and its clinical implication.
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Affiliation(s)
- Rajiv Sinha
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 700019, India.
| | | | - Sushmita Banerjee
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 700019, India
| | - Shakil Akhtar
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 700019, India
| | - Sanjukta Poddar
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 700019, India
| | - Deblina Dasgupta
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 700019, India
| | - Rana Saha
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 700019, India
| | - Jayati Sengupta
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 700019, India
| | - Mita Mandal
- All India Institute of Medical Sciences, Kalyani, India
| | - Yincent Tse
- Great North Children's Hospital, Newcastle Upon Tyne, UK
| | - Amitava Pahari
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 700019, India
- Apollo Multispecialty Hospital, Kolkata, India
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Cabrera Muras A, Gómez Muga JJ, Antón Méndez L, Barreras García A, García-Moncó JC. Pearls & Oy-sters: Frontal Lobe Syndrome Secondary to Cocaine-Induced Midline Destructive Lesions. Neurology 2024; 103:e209619. [PMID: 38900994 DOI: 10.1212/wnl.0000000000209619] [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: 06/22/2024] Open
Abstract
Cocaine-induced midline destructive lesions (CIMDL) are a rare complication of chronic intranasal cocaine use involving the centrofacial mucosal structures, often with nasal septum perforation and, in severe cases, involvement of neurocranial structures. Patients present with nasal obstruction, epistaxis, facial pain, nasal ulcerative lesions with crusting, and septal and palate perforation causing dysphagia and nasal reflux. CNS involvement is uncommon.We report a 47-year-old man with a history of nasal cocaine use who developed a subacute frontal syndrome secondary to cribriform plate destruction complicated by bilateral frontal lobe empyema and abscesses and extensive white matter involvement. The frequent presence of serum antineutrophil cytoplasmic antibodies (ANCA) in CIMDL makes this uncommon presentation challenging to differentiate from localized granulomatosis with polyangiitis. While ANCA antibodies may play a role in CIMDL, immunosuppression is not indicated and may lead to iatrogenesis.CIMDL should be considered in patients with isolated frontal lobe syndrome. Eliciting a history of cocaine use and obtaining toxicologic studies are essential in the diagnosis of CIMDL.
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Affiliation(s)
- Antonio Cabrera Muras
- From the Departments of Neurology (A.C.M., J.C.G.-M.), Radiology (J.J.G.M., L.A.M.), and Neurosurgery (A.B.G.), Basurto University Hospital, Osakidetza Basque Health Service, Bilbao, Spain
| | - Juan José Gómez Muga
- From the Departments of Neurology (A.C.M., J.C.G.-M.), Radiology (J.J.G.M., L.A.M.), and Neurosurgery (A.B.G.), Basurto University Hospital, Osakidetza Basque Health Service, Bilbao, Spain
| | - Lander Antón Méndez
- From the Departments of Neurology (A.C.M., J.C.G.-M.), Radiology (J.J.G.M., L.A.M.), and Neurosurgery (A.B.G.), Basurto University Hospital, Osakidetza Basque Health Service, Bilbao, Spain
| | - Ane Barreras García
- From the Departments of Neurology (A.C.M., J.C.G.-M.), Radiology (J.J.G.M., L.A.M.), and Neurosurgery (A.B.G.), Basurto University Hospital, Osakidetza Basque Health Service, Bilbao, Spain
| | - Juan Carlos García-Moncó
- From the Departments of Neurology (A.C.M., J.C.G.-M.), Radiology (J.J.G.M., L.A.M.), and Neurosurgery (A.B.G.), Basurto University Hospital, Osakidetza Basque Health Service, Bilbao, Spain
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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.
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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
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Alexander-Savino CV, Mirowski GW, Culton DA. Mucocutaneous Manifestations of Recreational Drug Use. Am J Clin Dermatol 2024; 25:281-297. [PMID: 38217568 DOI: 10.1007/s40257-023-00835-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2023] [Indexed: 01/15/2024]
Abstract
Recreational drug use is increasingly common in the dermatology patient population and is often associated with both general and specific mucocutaneous manifestations. Signs of substance use disorder may include changes to general appearance, skin, and mucosal findings associated with particular routes of drug administration (injection, insufflation, or inhalation) or findings specific to a particular drug. In this review article, we provide an overview of the mucocutaneous manifestations of illicit drug use including cocaine, methamphetamine, heroin, hallucinogens, marijuana, and common adulterants to facilitate the identification and improved care of these patients with the goal being to connect this patient population with appropriate resources for treatment.
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Affiliation(s)
- Carolina V Alexander-Savino
- State University of New York Upstate Medical University, Syracuse, NY, USA
- Department of Dermatology, University of North Carolina at Chapel Hill, 410 Market Street, Suite 400, Chapel Hill, NC, 27516, USA
| | - Ginat W Mirowski
- Department of Dermatology, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Oral Pathology, Medicine, Radiology, Indiana University School of Dentistry, Indianapolis, IN, USA
| | - Donna A Culton
- Department of Dermatology, University of North Carolina at Chapel Hill, 410 Market Street, Suite 400, Chapel Hill, NC, 27516, USA.
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Rose K, Iking-Konert C. [Secondary vasculitides]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:129-136. [PMID: 38265457 DOI: 10.1007/s00108-023-01654-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/18/2023] [Indexed: 01/25/2024]
Abstract
Vasculitides that occur in association with underlying primary diseases are called secondary vasculitides. In the diverse differential diagnostics of vasculitides, a large variety of secondary vasculitides have to be considered. Secondary vasculitides cover the full spectrum of vasculitides, presenting in manifold clinical manifestations. This article provides an overview of systemic diseases and etiological factors, such as infections, drugs, and malignancies, which can be associated with vasculitides. The possible associations with infectious agents are too numerous to be comprehensively covered and are discussed in an exemplary fashion and with a western European focus. Especially in atypical and refractory disease courses, a secondary vasculitis should be considered. In light of the diversity of differential diagnoses and the particular challenges posed by secondary vasculitides, interdisciplinary collaboration is the key for an accurate and early diagnosis as well as for successful treatment management. Treatment of the primary disease should always be prioritized and, if a drug-induced vasculitis is suspected, immediate cessation of the culprit drug is mandatory.
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Affiliation(s)
- Katharina Rose
- Abteilung für Rheumatologie, Stadtspital Zürich, Birmensdorferstraße 497, 8063, Zürich, Schweiz.
| | - Christof Iking-Konert
- Abteilung für Rheumatologie, Stadtspital Zürich, Birmensdorferstraße 497, 8063, Zürich, Schweiz
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Robinson K, Coraluzzi LM, Navarro VJ. Liver injury in patients with substance use disorder. Clin Liver Dis (Hoboken) 2024; 23:e0220. [PMID: 38912003 PMCID: PMC11191946 DOI: 10.1097/cld.0000000000000220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 04/15/2024] [Indexed: 06/25/2024] Open
Affiliation(s)
- Kevin Robinson
- Department of Medicine, Jefferson Einstein, Philadelphia, Pennsylvania, USA
| | - Lynda M. Coraluzzi
- Department of Medicine, Jefferson Einstein, Philadelphia, Pennsylvania, USA
| | - Victor J. Navarro
- Department of Medicine, Jefferson Einstein, Philadelphia, Pennsylvania, USA
- Department of Medicine, Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
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Koster MJ, Guarda M, Ghaffar U, Warrington KJ. Rheumatic masqueraders: mimics of primary vasculitis - a case-based review. Expert Rev Clin Immunol 2024; 20:83-95. [PMID: 37837326 DOI: 10.1080/1744666x.2023.2270774] [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: 03/31/2023] [Accepted: 10/10/2023] [Indexed: 10/16/2023]
Abstract
INTRODUCTION Vasculitis conditions are often serious and sometimes fatal diseases, therefore it is paramount to diagnose correctly and treat appropriately. Mimics of primary vasculitis can include either non-inflammatory syndromes or secondary vasculitis where the underlying etiology of the vasculitis is being driven by infection, malignancy, drug-effect or other. AREAS COVERED This review comprises six individual cases of vasculitis mimics. Each case is presented and the clinical, radiographic, and histological features that distinguish the case from primary vasculitis are highlighted. Key mimics in large, medium and small vessel vasculitis are outlined. EXPERT OPINION The diagnosis of vasculitis requires a comprehensive assessment of clinical, radiographic, and histologic features. Clinicians should be familiar with mimics of primary vasculitis conditions. In the case of non-inflammatory mimics, it is important to differentiate from primary vasculitides in order to avoid unnecessary and potentially harmful immunosuppression. For cases of secondary vasculitis, identification of the correct etiologic cause is critical because treatment of the underlying stimulus is necessary for successful management and outcomes.
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Affiliation(s)
- Matthew J Koster
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - Max Guarda
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - Umar Ghaffar
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - Kenneth J Warrington
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
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10
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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.
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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
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Wasserman I, Chari DA, Gray ST, Naunheim MR, Miloslavsky EM. Ear, Nose, and Throat Manifestations of Vasculitis and Other Systemic Autoimmune Diseases: Otologic, Sinus, and Airway. Rheum Dis Clin North Am 2023; 49:633-645. [PMID: 37331737 DOI: 10.1016/j.rdc.2023.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Auricular, nasal, and laryngeal manifestations occur frequently in rheumatic diseases. Inflammatory ear, nose, and throat (ENT) processes often result in organ damage and have profound effects on quality of life. Herein, we review the otologic, nasal, and laryngeal involvement of rheumatic diseases, focusing on their clinical presentation and diagnosis. ENT manifestations generally respond to treatment of the systemic disease, which is outside the scope of this review; however, adjunctive topical and surgical treatment approaches, as well as treatment of idiopathic inflammatory ENT manifestations will be reviewed.
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Affiliation(s)
- Isaac Wasserman
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Divya A Chari
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA; Department of Otolaryngology, University of Massachusetts Memorial Health Center, Worcester, MA, USA
| | - Stacey T Gray
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Matthew R Naunheim
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Eli M Miloslavsky
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Bucur P, Weber M, Agrawal R, Madera-Acosta AI, Elam RE. Pulmonary-Renal Syndrome from Levamisole-Adulterated Cocaine-Induced Antineutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis: A Systematic Review. Pharmaceuticals (Basel) 2023; 16:846. [PMID: 37375793 DOI: 10.3390/ph16060846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 05/29/2023] [Accepted: 05/31/2023] [Indexed: 06/29/2023] Open
Abstract
Levamisole is an anti-helminthic drug with immunomodulatory properties that is added to cocaine to increase its potency and weight. Levamisole-adulterated cocaine (LAC) may cause an antineutrophil cytoplasmic antibody (ANCA)-associated systemic small vessel vasculitis (AAV). We aimed to characterize the phenotype of persons developing pulmonary-renal syndrome (PRS) in LAC-induced AAV and summarize its treatment and outcomes. Pubmed and Web of Science were searched (until September 2022). Reports that described co-existing diffuse alveolar hemorrhage and glomerulonephritis in an adult (age ≥ 18) with confirmed or suspected LAC exposure were included. Reports, demographics, clinical and serologic features, treatment and outcome characteristics were extracted. Of the 280 records identified, eight met the inclusion criteria, including eight unique cases. Persons were aged 22-58 years, and 50% were women. Cutaneous involvement occurred in only half of the cases. Other associated vasculitis findings and serologies were heterogeneous. All patients received immunosuppression with steroids, with cyclophosphamide and rituximab commonly added. We concluded that PRS could occur from LAC-induced AAV. Distinguishing LAC-induced AAV from primary AAV is challenging as clinical and serologic presentations overlap. Asking about cocaine use is requisite in persons presenting with PRS to guide diagnosis and appropriately counsel on cocaine cessation in conjunction with immunosuppression as treatment.
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Affiliation(s)
- Philip Bucur
- Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
- Charlie Norwood Veterans Affairs Medical Center, Augusta, GA 30901, USA
| | - Marshall Weber
- Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Rashi Agrawal
- Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | | | - Rachel E Elam
- Charlie Norwood Veterans Affairs Medical Center, Augusta, GA 30901, USA
- Division of Rheumatology, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
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13
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Canetta PA. Right Heart, Wronged Kidneys. Clin J Am Soc Nephrol 2023; 18:813-815. [PMID: 36988331 PMCID: PMC10278778 DOI: 10.2215/cjn.0000000000000154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/17/2023] [Indexed: 03/30/2023]
Affiliation(s)
- Pietro A Canetta
- Nephrology Division, Columbia University Irving Medical Center, New York, New York
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14
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Thammathiwat T, Banjongjit A, Iampenkhae K, Townamchai N, Kanjanabuch T. ANCA Associated Glomerulonephritis Following SARS-CoV-2 Vaccination: A Case Series and Systematic Review. Vaccines (Basel) 2023; 11:vaccines11050983. [PMID: 37243087 DOI: 10.3390/vaccines11050983] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/02/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
Vaccines against SARS-CoV-2 (COVID-19) proved beneficial for COVID-19 disease attenuation and preventing virus spreading. Cumulative reports of the rarity of antineutrophil cytoplasmic autoantibodies (ANCA)-associated vasculitis (AAV) raise concerns about its relationship with COVID-19 vaccination. Several case reports described ANCA-associated pauci-immune glomerulonephritis (ANCA-GN) following COVID-19 vaccination with some uniqueness. We systematically reviewed COVID-19 vaccine-induced ANCA-GN from PubMed, SCOPUS, and Cochrane library databases until 1 January 2023 according to PRISMA guidelines and presented our three cases. Twenty-six cases from 25 articles, including our 3 cases, were analyzed. Most cases were diagnosed following the second dose of the COVID-19 vaccine (59%) with a median (IQR) interval onset of 14 (16) days. The highest prevalence was related to the mRNA-type vaccine. Anti-myeloperoxidase (MPO) ANCA was far more common than the other ANCAs, with various positive autoantibodies. Fourteen cases (out of 29 cases, 48%) had extra-kidney AAV manifestation. Although severe kidney injury was observed in 10/29 (34%), remission was achieved in 89% (25/28) with no death. The mechanisms of the vaccine-inducing ANCA-GN were postulated here. Since ANCA-GN after the COVID-19 vaccine was rare, the benefit of the COVID-19 vaccine could outweigh the risk of ANCA-GN side effects in the pandemic era.
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Affiliation(s)
- Theerachai Thammathiwat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Naresuan University, Phitsanulok 65000, Thailand
| | - Athiphat Banjongjit
- Nephrology Unit, Department of Medicine, Vichaiyut Hospital, Bangkok 10400, Thailand
| | - Kroonpong Iampenkhae
- Department of Pathology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Natavudh Townamchai
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
- Excellence Center for Solid Organ Transplantation, King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
- Renal Immunology and Renal Transplant Research Unit, Chulalongkorn University, Bangkok 10330, Thailand
| | - Talerngsak Kanjanabuch
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
- Center of Excellence in Kidney Metabolic Disorders, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
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15
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van Leuven SI. Hidden in plain sight: how to look behind the veil of cocaine-induced vasculitis. Rheumatol Adv Pract 2023; 7:rkad047. [PMID: 37207269 PMCID: PMC10191674 DOI: 10.1093/rap/rkad047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 05/21/2023] Open
Affiliation(s)
- Sander I van Leuven
- Correspondence to: Sander I. van Leuven, Department of Rheumatology, Radboud University Medical Center, Geert Grooteplein 10, 6525 GA, Nijmegen, The Netherlands. E-mail:
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16
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Keim CK, Schwartz RA, Kapila R. Levamisole-induced and COVID-19-induced retiform purpura: two overlapping, emerging clinical syndromes. Arch Dermatol Res 2023; 315:265-273. [PMID: 34807290 PMCID: PMC8607060 DOI: 10.1007/s00403-021-02303-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 11/11/2021] [Indexed: 10/28/2022]
Abstract
Levamisole exposure in cocaine users is a well-recognized cause of retiform purpura, a distinctive net-like maculopapular patch. Prolonged exposure to levamisole can lead to a serious systemic syndrome known as levamisole-induced vasculitis, most commonly involving the kidneys and lungs. More recently, retiform purpura has been observed in patients with the novel coronavirus disease of 2019 (COVID-19). Due to their overlapping dermatologic and systemic manifestations, levamisole-induced and COVID-19-induced retiform purpura may mimic one another in clinical presentation. The possibility that patients may present with one or both syndromes creates a diagnostic challenge. This review of levamisole-induced and COVID-19-induced retiform purpura highlights their corresponding and distinctive features. Additionally, we propose a unique staging system for levamisole-induced retiform purpura that may be valid for future classification of COVID-19-induced retiform purpura.
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Affiliation(s)
- Catherine K. Keim
- grid.430387.b0000 0004 1936 8796Rutgers New Jersey Medical School, MSB H-576, 185 South Orange Ave, Newark, NJ 07103 USA
| | - Robert A. Schwartz
- grid.430387.b0000 0004 1936 8796Dermatology and Pathology, Rutgers New Jersey Medical School, MSB H-576, 185 South Orange Ave, Newark, NJ 07103 USA
| | - Rajendra Kapila
- grid.430387.b0000 0004 1936 8796Infectious Diseases, Rutgers New Jersey Medical School, MSB H-576, 185 South Orange Ave, Newark, NJ 07103 USA
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17
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Triple Jeopardy: Rapidly Progressive Glomerulonephritis Induced by Triple Seropositive Disease—A Rare Case. Case Rep Med 2022; 2022:2032525. [PMID: 36419545 PMCID: PMC9678450 DOI: 10.1155/2022/2032525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 10/22/2022] [Accepted: 11/04/2022] [Indexed: 11/15/2022] Open
Abstract
The double-positive disease is the co-occurrence of antiglomerular basement membrane (anti-GBM) disease and antineutrophil cytoplasmic antibodies (ANCAs) and is an uncommon cause of renal failure. Our case of triple-positive disease is an even rarer cause of isolated renal failure, as it includes anti-GBM, antimyeloperoxidase (MPO), and antiproteinase 3 (PR3). We present a case of a 62-year-old Caucasian male with a history of multiple comorbidities, who presented to the emergency department (ED) with worsening dyspnea on exertion that started about one month prior to admission. He was found to be in renal failure secondary to triple-positive disease. We believe that the likely mechanism of our patient's triple-positive disease was a drug-induced ANCA vasculitis overlapping with Goodpasture's syndrome. We believe our case to be a valuable addition to the literature as it is a rare overlap syndrome without a previously established disease course or etiology.
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18
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Folci M, Ramponi G, Solitano V, Brunetta E. Serum ANCA as Disease Biomarkers: Clinical Implications Beyond Vasculitis. Clin Rev Allergy Immunol 2022; 63:107-123. [PMID: 34460071 DOI: 10.1007/s12016-021-08887-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2021] [Indexed: 01/13/2023]
Abstract
Usually associated with autoimmune diseases, anti-neutrophil cytoplasmic antibodies are also detected in other conditions, such as infections, malignancies, and after intake of certain drugs. Even if the mechanisms of production and their pathogenic role have not been fully elucidated yet, ANCA are widely recognized as a clinically alarming finding due to their association with various disorders. While ANCA target several autoantigens, proteinase-3, and myeloperoxidase are the ones proved to be most frequently related to chronic inflammation and tissue damage in murine models. Albeit these autoantibodies could be present as an isolated observation without any implications, ANCA are frequently used in clinical practice to guide the diagnosis in a suspect of small vessel vasculitis. Conditions that should prompt the clinician to test ANCA status range from various forms of lung disease to renal or peripheral nervous system impairment. ANCA positivity in the presence of an autoimmune disease, especially rheumatoid arthritis, or connective tissue diseases, is frequently correlated with more clinical complications and treatment inefficacy, even in the absence of signs of vasculitis. For this reason, it has been postulated that ANCA could represent the final expression of an immune dysregulation rather than a pathogenic event responsible for organs damage. Recently, it has also been proposed that ANCA specificity (PR3 or MPO) could possibly define ANCA-associated vasculitides better than clinical phenotype. This review aims at summarizing the latest advancements in the field of ANCA study and clinical interpretation.
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Affiliation(s)
- Marco Folci
- Humanitas Clinical and Research Center - IRCCS, Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.
| | | | - Virginia Solitano
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Enrico Brunetta
- Humanitas Clinical and Research Center - IRCCS, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
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19
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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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20
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Martin K, Deleveaux S, Cunningham M, Ramaswamy K, Thomas B, Lerma E, Madariaga H. The presentation, etiologies, pathophysiology, and treatment of pulmonary renal syndrome: A review of the literature. Dis Mon 2022; 68:101465. [PMID: 36008166 DOI: 10.1016/j.disamonth.2022.101465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Pulmonary renal syndrome (PRS) is a constellation of different disorders that cause both rapidly progressive glomerulonephritis and diffuse alveolar hemorrhage. While antineutrophil cytoplasmic antibody associated vasculitis and anti-glomerular basement membrane disease are the predominant causes of PRS, numerous other mechanisms have been shown to cause this syndrome, including thrombotic microangiopathies, drug exposures, and infections, among others. This syndrome has high morbidity and mortality, and early diagnosis and treatment is imperative to improve outcomes. Treatment generally involves glucocorticoids and immunosuppressive agents, but treatment targeted to the underlying disorder can improve outcomes and mitigate side effects. Familiarity with the wide range of possible causes of PRS can aid the clinician in workup, diagnosis and early initiation of treatment. This review provides a summary of the clinical presentation, etiologies, pathophysiology, and treatment of PRS.
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Affiliation(s)
| | | | | | | | - Beje Thomas
- Medstar Georgetown University Hospital, United States
| | - Edgar Lerma
- Advocate Christ Medical Center, United States
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21
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Yaseen K, Mandell BF. ANCA Associated Vasculitis (AAV): A Review for Internists. Postgrad Med 2022; 135:3-13. [PMID: 35831990 DOI: 10.1080/00325481.2022.2102368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) compromise a rare group of necrotizing small to medium vessel vasculitides that constitute three distinct disorders: granulomatosis with polyangiitis (GPA) (formerly known as Wegener's granulomatosis), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA) (formerly known as Churg-Strauss syndrome).AAV is characterized by the usual presence of circulating autoantibodies to the neutrophil proteins leukocyte proteinase 3 (PR3-ANCA) or myeloperoxidase (MPO-ANCA). These antibodies can activate neutrophils and the complement system resulting in vessel wall inflammation and damage.The clinical presentation of AAV varies from non-severe (non-life threatening) to severe often with potentially life-threatening multi-organ involvement. Early recognition and diagnosis are crucial. In the past two decades, advances in understanding the pathophysiology of AAV have led to development of new treatments and resulted in significant improvement in general outcomes and survival rates.This narrative review will focus on GPA and MPA. We will highlight clinical manifestations, diagnosis, disease monitoring, and treatment strategies in patients with AAV.
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Affiliation(s)
- Kinanah Yaseen
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, 9500 Euclid Avenue/A50 Cleveland, Ohio 44195, USA
| | - Brian F Mandell
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, 9500 Euclid Avenue/A50 Cleveland, Ohio 44195, USA
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22
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Sunu SY, Dhaduk K. Levamisole-Adulterated Cocaine-Induced Thrombotic Vasculopathy With Negative Serology. Cureus 2022; 14:e26594. [PMID: 35936149 PMCID: PMC9354916 DOI: 10.7759/cureus.26594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2022] [Indexed: 11/09/2022] Open
Abstract
Substance abuse is an important public health issue in the United States. The prevalence of cocaine use is wide, and it is noted to be adulterated with a substance called levamisole, which can increase the bulk and possibly potentiate cocaine’s euphoric effect. Literature shows that levamisole-induced vasculopathy has a strong association with antineutrophil cytoplasmic antibodies (ANCA) antibodies. However, we report a case of biopsy-confirmed levamisole-related thrombotic vasculopathy with negative perinuclear antineutrophil cytoplasmic antibody (p-ANCA) and cytoplasmic antineutrophil cytoplasmic autoantibody (c-ANCA) antibodies. Our case highlights the serious consequences of substance abuse. Here, we provide educational value and encourage physicians to keep the differentials broad when encountering a dermatological case in patients with cocaine use and highlight the importance of skin biopsy for the diagnosis and appropriate management.
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23
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Cocaine/Levamisole-Induced, Skin-Limited ANCA-Associated Vasculitis with Pyoderma Gangrenosum-like Presentation. Dermatopathology (Basel) 2022; 9:207-211. [PMID: 35892479 PMCID: PMC9326590 DOI: 10.3390/dermatopathology9030026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/03/2022] [Accepted: 06/17/2022] [Indexed: 11/17/2022] Open
Abstract
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.
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24
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Baier E, Olgemöller U, Biggemann L, Buck C, Tampe B. Dual-Positive MPO- and PR3-ANCA-Associated Vasculitis Following SARS-CoV-2 mRNA Booster Vaccination: A Case Report and Systematic Review. Vaccines (Basel) 2022; 10:vaccines10050653. [PMID: 35632410 PMCID: PMC9148036 DOI: 10.3390/vaccines10050653] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/13/2022] [Accepted: 04/16/2022] [Indexed: 02/01/2023] Open
Abstract
As the coronavirus disease 2019 (COVID-19) pandemic is ongoing, and new variants of severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) are emerging, vaccines are needed to protect individuals at high risk of complications and to potentially control disease outbreaks by herd immunity. After SARS-CoV-2 vaccination, antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) presenting with a pulmonary hemorrhage has been described. Previous studies suggested that monocytes upregulate major histocompatibility complex (MHC) II cell surface receptor human leukocyte antigen receptor (HLA-DR) molecules in granulomatosis with polyangiitis (GPA) patients with proteinase 3 (PR3)- and myeloperoxidase (MPO)-ANCA seropositivity. Here, we present a case of new-onset AAV after booster vaccination with the Pfizer-BioNTech SARS-CoV-2 mRNA vaccine. Moreover, we provide evidence that the majority of monocytes express HLA-DR in AAV after SARS-CoV-2 booster vaccination. It is possible that the enhanced immune response after booster vaccination and presence of HLA-DR+ monocytes could be responsible for triggering the production of the observed MPO- and PR3-ANCA autoantibodies. Additionally, we conducted a systematic review of de novo AAV after SARS-CoV-2 vaccination describing their clinical manifestations in temporal association with SARS-CoV-2 vaccination, ANCA subtype, and treatment regimens. In light of a hundred million individuals being booster vaccinated for SARS-CoV-2 worldwide, a potential causal association with AAV may result in a considerable subset of cases with potential severe complications.
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Affiliation(s)
- Eva Baier
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, 37085 Göttingen, Germany;
| | - Ulrike Olgemöller
- Department of Cardiology and Pneumology, University Medical Center Göttingen, 37085 Göttingen, Germany; (U.O.); (C.B.)
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, 37099 Göttingen, Germany
| | - Lorenz Biggemann
- Institute of Diagnostic and Interventional Radiology, University Medical Center Göttingen, 37085 Göttingen, Germany;
| | - Cordula Buck
- Department of Cardiology and Pneumology, University Medical Center Göttingen, 37085 Göttingen, Germany; (U.O.); (C.B.)
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, 37099 Göttingen, Germany
| | - Björn Tampe
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, 37085 Göttingen, Germany;
- Correspondence: ; Tel.: +49-551-391-0575
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25
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Abstract
There is increasing understanding that a multifaceted interplay of sex-dependent genetic and immune dysregulation underpins the development of glomerular disorders. Regional and ethnic variations in glomerular disease incidence make delineating the effects of sex and gender on disease pathophysiology more complex, but there is a marked paucity of research in this area. This review article presents a summary of the current understanding of sex and gender in glomerular disease, highlighting the broader effects of sex and gender on autoimmunity, clinical presentations, and pathophysiology of individual glomerular diseases, as well as exploring sex, gender, and glomerular disease within a wider socioenvironmental context. It is important to specifically consider the effects of sex and gender when presenting and analyzing clinical and scientific studies on glomerular disease. Failure to do so risks promoting disparities within health care provision, neglecting opportunities to identify sex-specific biomarkers, and potentially hindering the development of sex-specific therapies.
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Affiliation(s)
- Hannah Beckwith
- Department of Renal Medicine, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK.
| | - Liz Lightstone
- Department of Renal Medicine, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - Steve McAdoo
- Department of Renal Medicine, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK
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26
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Saha BK, Chong WH, Milman NT. Differentiation of idiopathic pulmonary hemosiderosis from rheumatologic and autoimmune diseases causing diffuse alveolar hemorrhage: establishing a diagnostic approach. Clin Rheumatol 2022; 41:325-336. [PMID: 34491458 DOI: 10.1007/s10067-021-05895-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 12/11/2022]
Abstract
This narrative review provides an overview of diffuse alveolar hemorrhage (DAH) associated with rheumatologic and autoimmune diseases and their differentiation from idiopathic pulmonary hemosiderosis (IPH). Relevant immunologic diseases associated with DAH are discussed, and a diagnostic flowchart is proposed to establish a "definitive" diagnosis of IPH within the spectrum of DAH. IPH is a rare cause of recurrent DAH both in children and adults. In adults, a definitive diagnosis of IPH requires a lung biopsy and histopathologic examination demonstrating intraalveolar hemorrhage, hemosiderin-laden macrophages, and a variable degree of fibrosis in the absence of both capillaritis and cellular inflammation. The presence of small vessel vasculitis points towards immunologic, well-differentiated, or sometimes undifferentiated rheumatologic diseases. However, it is essential to recognize that many rheumatologic diseases may in the initial phase present with DAH without any evidence of capillaritis, thus mimicking IPH. Although not definitely established, it is likely that immunologic processes are involved in IPH, and we, therefore, suggest the consideration of a more suitable term for the disease, e.g., "Immune-mediated Pulmonary Hemosiderosis" to acknowledge the aberrancy in the immune parameters and a positive response to immunosuppressive therapy.
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Affiliation(s)
- Biplab K Saha
- Division of Pulmonary and Critical Care Medicine, Ozarks Medical Center, West Plains, MO, USA.
| | - Woon H Chong
- Division of Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY, USA
| | - Nils T Milman
- Department of Clinical Biochemistry, Næstved Hospital, University College Zealand, 4700, Næstved, Denmark
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27
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Vondenberg JA, Trost JR, Redford AH, Farshami FJ, Muruganandam M, Sibbitt WL. Atypical Chronic Deforming Arthritis After Cocaine-Levamisole Exposure. J Clin Rheumatol 2021; 27:S384-S386. [PMID: 32658048 DOI: 10.1097/rhu.0000000000001484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Jaime A Vondenberg
- Division of Rheumatology and School of Medicine Department of Internal Medicine University of New Mexico Health Sciences Center Albuquerque, NM
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28
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Yap BJM, Lai-Foenander AS, Goh BH, Ong YS, Duangjai A, Saokaew S, Chua CLL, Phisalprapa P, Yap WH. Unraveling the Immunopathogenesis and Genetic Variants in Vasculitis Toward Development of Personalized Medicine. Front Cardiovasc Med 2021; 8:732369. [PMID: 34621800 PMCID: PMC8491767 DOI: 10.3389/fcvm.2021.732369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/26/2021] [Indexed: 12/23/2022] Open
Abstract
Leukocytoclastic vasculitis (LCV) is a systemic autoimmune disease characterized by the inflammation of the vascular endothelium. Cutaneous small vessel vasculitis (CSVV) and anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) are two examples of LCV. Advancements in genomic technologies have identified risk haplotypes, genetic variants, susceptibility loci and pathways that are associated with vasculitis immunopathogenesis. The discovery of these genetic factors and their corresponding cellular signaling aberrations have enabled the development and use of novel therapeutic strategies for vasculitis. Personalized medicine aims to provide targeted therapies to individuals who show poor response to conventional interventions. For example, monoclonal antibody therapies have shown remarkable efficacy in achieving disease remission. Here, we discuss pathways involved in disease pathogenesis and the underlying genetic associations in different populations worldwide. Understanding the immunopathogenic pathways in vasculitis and identifying associated genetic variations will facilitate the development of novel and targeted personalized therapies for patients.
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Affiliation(s)
- Bryan Ju Min Yap
- School of Biosciences, Taylor's University, Subang Jaya, Malaysia
| | | | - Bey Hing Goh
- Biofunctional Molecule Exploratory Research Group (BMEX), School of Pharmacy, Monash University Malaysia, Bandar Sunway, Malaysia.,College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Yong Sze Ong
- Biofunctional Molecule Exploratory Research Group (BMEX), School of Pharmacy, Monash University Malaysia, Bandar Sunway, Malaysia
| | - Acharaporn Duangjai
- Unit of Excellence in Research and Product Development of Coffee, Division of Physiology, School of Medical Sciences, University of Phayao, Phayao, Thailand.,Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand.,Unit of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - Surasak Saokaew
- Unit of Excellence in Research and Product Development of Coffee, Division of Physiology, School of Medical Sciences, University of Phayao, Phayao, Thailand.,Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand.,Unit of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand.,Unit of Excellence on Herbal Medicine, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand.,Division of Pharmacy Practice, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | | | - Pochamana Phisalprapa
- Division of Ambulatory Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Wei Hsum Yap
- School of Biosciences, Taylor's University, Subang Jaya, Malaysia.,Centre for Drug Discovery and Molecular Pharmacology (CDDMP), Faculty of Health and Medical Sciences (FHMS), Taylor's University, Subang Jaya, Malaysia
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29
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Vermeulen L, Dirix M, Dendooven A. Cocaine Consumption and Antineutrophil Cytoplasmic Antibody-associated Glomerulonephritis: A Case Report. Am J Forensic Med Pathol 2021; 42:198-200. [PMID: 33186130 DOI: 10.1097/paf.0000000000000618] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Cocaine is often sold in a mixture with levamisole to increase the profit margin and potentiate the euphoric effect. Apart from an overdose, cocaine can induce a wide range of clinical symptoms. We present a case of cocaine/levamisole-induced pauci-immune glomerulonephritis. A 22-year-old patient was sent to the hospital after a laboratory result showed an unexpected acute kidney injury, with an estimated glomerular filtration rate of 34 mL/min/1.73 m2. The medical history included cocaine abuse. Renal biopsy showed a pauci-immune necrotizing glomerulonephritis. Antineutrophil cytoplasmic antibodies were positive with a perinuclear staining pattern and target specificity for leucocyte myeloperoxidase (antimyeloperoxidase). Despite treatment, the kidney function did not show significant improvement. The forensic implication of this case is that even if the toxicological values are not high enough to suggest a lethal intoxication, an idiosyncratic reaction on cocaine and/or levamisole has to be taken into account.
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Abousy M, Sylvester S, Milek D, Hultman CS, Caffrey J. Surgical management and outcomes of levamisole-induced vasculitis in a burn center: A case series. JAAD Case Rep 2021; 13:36-42. [PMID: 34136623 PMCID: PMC8182369 DOI: 10.1016/j.jdcr.2021.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Mya Abousy
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Scott Sylvester
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - David Milek
- Department of Surgery, University of Rochester School of Medicine, Rochester, New York
| | - C Scott Hultman
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Julie Caffrey
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
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Yang CW, Li S, Dong Y, Paliwal N, Wang Y. Epidemiology and the Impact of Acute Kidney Injury on Outcomes in Patients with Rhabdomyolysis. J Clin Med 2021; 10:jcm10091950. [PMID: 34062839 PMCID: PMC8125267 DOI: 10.3390/jcm10091950] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/23/2021] [Accepted: 04/25/2021] [Indexed: 01/04/2023] Open
Abstract
Background: Currently, no large, nationwide studies have been conducted to analyze the demographic factors, underlying comorbidities, clinical outcomes, and health care utilization in rhabdomyolysis patients with and without acute kidney injury (AKI). Methods: We queried the National Inpatient Sample of Healthcare Cost and Utilization Project (HCUP) with patients with rhabdomyolysis from 2016 to 2018. The chi-squared test was used to compare categorical variables, and the adjusted Wald test was employed to compare quantitative variables. The logistic regression model was applied to calculate adjusted odds ratios (ORs) with 95% confidence intervals (95% CIs) to estimate the impact of AKI on outcomes in patients with rhabdomyolysis. Results: Among 111,085 rhabdomyolysis-related hospitalizations, a higher prevalence of AKI was noticed in older patients (mean age ± SD, 58.2 ± 21.6 vs. 53.8 ± 22.2), Medicare insurance (48.5% vs. 43.2%), and patients with a higher Charlson Comorbidity Index score (CCI 3–5, 15.1% vs. 5.5%). AKI was found to be independently associated with higher mortality (adjusted odds ratio [aOR] 3.33, 95% CI 2.33–4.75), longer hospital stays (adjusted difference 1.17 days, 95% CI: 1.00−1.34), and higher cost of hospital stay (adjusted difference $11,315.05, 95% CI: $9493.02–$13,137.07). Conclusions: AKI in patients hospitalized with rhabdomyolysis is related to adverse clinical outcomes and significant economic and survival burden.
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Affiliation(s)
- Chien-Wen Yang
- Renal Electrolyte and Hypertension Division, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, USA;
| | - Si Li
- Department of Internal Medicine, Wright Center for Graduate Medical Education, 501 S Washington Ave, Scranton, PA 18505, USA;
- Correspondence:
| | - Yishan Dong
- Department of Internal Medicine, Rochester General Hospital, 1425 Portland Ave, Rochester, NY 14621, USA;
| | - Nitpriya Paliwal
- Department of Internal Medicine, Wright Center for Graduate Medical Education, 501 S Washington Ave, Scranton, PA 18505, USA;
| | - Yichen Wang
- Mercy Internal Medicine Service, Trinity Health of New England, 271 Carew St, Springfield, MA 01104, USA;
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Annangi S, Pasha S. Isotretinoin induced small vessel vasculitis: a life-threatening pulmonary-renal syndrome-a case report. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:584. [PMID: 33987282 DOI: 10.21037/atm-20-4212] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Oral isotretinoin is a synthetic analog of vitamin - A, reserved for cases with severe resistant acne. We hereby report a case of drug-induced vasculitis (DV) from isotretinoin exposure leading to life-threatening pulmonary-renal syndrome requiring immunosuppression and plasmapheresis. A previously healthy 21-year-old female receiving oral isotretinoin presented with a 10-day history of worsening myalgias, arthralgias, and abdominal pain. Soon after admission she progressed to severe pulmonary-renal syndrome requiring intubation and renal replacement therapy. Urinalysis revealed >50 dysmorphic RBC with casts and renal ultrasound was unremarkable. Serological testing was only positive for antineutrophil cytoplasmic antibodies (ANCA) at 1:80 with Anti- proteinase 3 (PR3) at 830 AU/mL and Anti-histone Ab at 2.9. As clinical presentation and serology are highly suggestive of ANCA associated DV, plasmapheresis, and rituximab were also initiated along with the continuation of steroids. She clinically improved but remained dialysis dependent and received a live donor renal transplant. The temporal relationship of symptom onset and drug initiation with no other possible identifiable etiologies-DV in our case was attributed to isotretinoin exposure. Though considered safe, oral Isotretinoin in rare instances can cause the life-threatening pulmonary-renal syndrome. Given its widespread use, it is prudent that prescribers should educate patients regarding the possible symptoms of vasculitis and to seek immediate medical attention when warranted. Physicians should also be vigilant of this complication and should act swiftly to avoid uneventful outcomes.
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Affiliation(s)
- Srinadh Annangi
- University of Kentucky College of Medicine, Division of Pulmonary Critical Care and Sleep Medicine, Lexington, KY, USA.,Department of Pulmonary and Critical Care Medicine, Harrison Memorial Hospital, Cynthiana, KY, USA
| | - Sara Pasha
- University of Kentucky College of Medicine, Division of Pulmonary Critical Care and Sleep Medicine, Lexington, KY, USA
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Bond M, Fagni F, Vaglio A. ANCA testing: where are we now? Intern Emerg Med 2021; 16:269-271. [PMID: 33385295 DOI: 10.1007/s11739-020-02584-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 11/20/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Milena Bond
- Department of Medicine, Rheumatology Clinic, S. Chiara Hospital, Trento, Italy
| | - Filippo Fagni
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Augusto Vaglio
- Nephrology and Dialysis Unit, Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", Meyer Children's Hospital, University of Firenze, Viale Pieraccini 6, 50139, Florence, Italy.
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34
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Ramponi G, Folci M, De Santis M, Damoiseaux JGMC, Selmi C, Brunetta E. The biology, pathogenetic role, clinical implications, and open issues of serum anti-neutrophil cytoplasmic antibodies. Autoimmun Rev 2021; 20:102759. [PMID: 33476813 DOI: 10.1016/j.autrev.2021.102759] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 12/05/2020] [Indexed: 12/11/2022]
Abstract
Anti-neutrophil cytoplasmic antibodies (ANCA) are a group of autoantibodies, predominantly IgG, involved in the pathogenesis of several autoimmune disorders, detected either through indirect immunofluorescence or enzyme-linked immunosorbent assay. By means of indirect immunofluorescence, the main patterns are C-ANCA (cytoplasmic) and P-ANCA (perinuclear), while proteinase 3 (PR3) and myeloperoxidase (MPO) represent the main autoantigens in granulomatosis with polyangiitis and microscopic polyangiitis, both belonging to the family of ANCA-associated vasculitis (AAV). While several experiments established the pathogenicity of MPO-ANCA, evidence remains elusive for PR3-ANCA and an additional target antigen, i.e. LAMP2, has been postulated with specific clinical relevance. The presence of a subset of AAV without ANCA may be explained by the presence of further target antigens or the presence of molecules in blood which make ANCA undetectable. A rise in ANCA titers is not necessarily predictive of a flare of disease in AAV if not accompanied by clinical manifestations. ANCA may develop through variable mechanisms, such as autoantigen complementarity, apoptosis impairment, neutrophil extracellular traps dysfunction and molecular mimicry. We will provide herein a comprehensive review of the available evidence on the biological mechanisms, pathogenetic role, and clinical implications of ANCA testing and disease management. Further, we will address the remaining open challenges in the field, including the role of ANCA in inflammatory bowel disease and in cocaine-induced vasculitis.
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Affiliation(s)
- Giacomo Ramponi
- Humanitas Clinical and Research Center - IRCCS, 20089, Rozzano, Milan, Italy
| | - Marco Folci
- Humanitas Clinical and Research Center - IRCCS, 20089, Rozzano, Milan, Italy
| | - Maria De Santis
- Humanitas Clinical and Research Center - IRCCS, 20089, Rozzano, Milan, Italy
| | - Jan G M C Damoiseaux
- Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, Netherlands
| | - Carlo Selmi
- Humanitas Clinical and Research Center - IRCCS, 20089, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy.
| | - Enrico Brunetta
- Humanitas Clinical and Research Center - IRCCS, 20089, Rozzano, Milan, Italy
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Atypical Chronic Inflammatory ANCA-Positive Deforming Arthritis After Cocaine-Levamisole Exposure. J Clin Rheumatol 2020; 26:24-32. [PMID: 30273264 DOI: 10.1097/rhu.0000000000000910] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND/OBJECTIVE Immunostimulatory drugs including immune checkpoint inhibitors and levamisole can induce inflammatory disease including vasculitis, rashes, tissue necrosis, and arthritis. METHODS This prospective cohort study determined the 5-year outcomes of cocaine-levamisole-induced inflammatory disease as to outcomes and survival. Thirty-one consecutive cocaine-levamisole autoimmune patients and 45 primary vasculitis patients were characterized as to clinical differentiating features, antineutrophil cytoplasmic antibody (ANCA) status, treatment, the presence of acute and chronic arthritis, and 5-year outcome. RESULTS Seventy-one percent (22/31) of cocaine-levamisole vasculopathy cases were ANCA positive (86% p-ANCA and 14% c-ANCA), whereas 53% (23/45) of the primary vasculitis were ANCA positive (p = 0.04). The ANCA-positive cocaine-levamisole cohort at onset were characterized by younger age (45 ± 12 vs 53 ± 14 years, p = 0.04), superficial skin necrosis (82% vs 54%, p = 0.036), depressed complement C3 (27% vs 4%, p = 0.33), antiphospholipid antibodies (50% vs 4%, p < 0.001), neutropenia (18% vs 0%, p = 0.044), and elevated antimyeloperoxidase (MPO) antibody levels (100% vs 67%, p < 0.001). Chronic cocaine-levamisole disease was characterized by severe cicatrical deformities of the face and extremities (45.5% vs 8.3%, p = 0.005). Arthralgias (71% vs 82%, p = 0.19) and acute arthritis (33% vs 32%, p = 0.25) were similar between the 2 groups. However, a substantial proportion cocaine-levamisole-induced autoimmune patients (18% vs 0%, p = 0.045) developed a chronic deforming inflammatory arthritis that was rheumatoid factor, anti-cyclic-citrillinated antibody antibody, and HLA-B27 negative, but p-ANCA-and MPO antibody positive. CONCLUSIONS Patients exposed to cocaine-levamisole may develop serious chronic sequelae including cicatrical cutaneous and facial deformities and an atypical seronegative, p-ANCA and MPO antibody-positive, HLA-B27-negative chronic deforming inflammatory arthritis.
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36
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A 50-Year-Old Woman With Confusion and Facial Rash. Chest 2020; 157:e37-e40. [PMID: 32033659 DOI: 10.1016/j.chest.2019.08.2207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 08/04/2019] [Accepted: 08/25/2019] [Indexed: 11/23/2022] Open
Abstract
CASE PRESENTATION A 50-year-old woman presented to the ED with a 3-day history of increasing confusion. Prior to her presentation, the patient had been in her usual state of health as reported by her family. She had a history of bipolar disorder and attention-deficit/hyperactivity disorder but had stopped her psychiatric medications for the past 4 days secondary to loss of insurance coverage. History was limited due to the patient's altered state and confusion, and was obtained from family. There was no history of headache, loss of consciousness, weakness of extremities, seizures, fever, or recent trauma. The patient's medical history also included cocaine abuse. The patient's family believed she had been abstinent from cocaine use for several years.
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37
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A case series and literature review on patients with rhinological complications secondary to the use of cocaine and levamisole. The Journal of Laryngology & Otology 2020; 134:440-446. [PMID: 32431257 DOI: 10.1017/s0022215120000894] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Levamisole is an increasingly common cutting agent used with cocaine. Both cocaine and levamisole can have local and systemic effects on patients. METHODS A retrospective case series was conducted of patients with a cocaine-induced midline destructive lesion or levamisole-induced vasculitis, who presented to a Dundee hospital or the practice of a single surgeon in Paisley, from April 2016 to April 2019. A literature review on the topic was also carried out. RESULTS Nine patients from the two centres were identified. One patient appeared to have levamisole-induced vasculitis, with raised proteinase 3, perinuclear antineutrophil cytoplasmic antibodies positivity and arthralgia which improved on systemic steroids. The other eight patients had features of a cocaine-induced midline destructive lesion. CONCLUSION As the use of cocaine increases, ENT surgeons will see more of the complications associated with it. This paper highlights some of the diagnostic issues and proposes a management strategy as a guide to this complex patient group. Often, multidisciplinary management is needed.
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Restrepo-Escobar M, Sylva D, Gamboa JG, Echeverri A, Márquez J, Pinto LF. Pulmonary-renal syndrome secondary to cocaine-levamisole-induced vasculitis: A case report. REUMATOLOGIA CLINICA 2020; 16:239-241. [PMID: 29784435 DOI: 10.1016/j.reuma.2018.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 02/14/2018] [Accepted: 02/20/2018] [Indexed: 06/08/2023]
Abstract
Pulmonary-renal syndrome has rarely been reported as the clinical presentation of vasculitis caused by the consumption of cocaine adulterated with levamisole. We report the case of a patient in whom we detected the clinical manifestations and indicate the difficulties that arose in relation to the diagnostic and therapeutic approach.
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Affiliation(s)
- Mauricio Restrepo-Escobar
- Sección de Reumatología, Hospital Pablo Tobón Uribe, Medellín, Colombia; Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia.
| | - Dayana Sylva
- Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Juan Guillermo Gamboa
- Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia; Sección de Medicina Interna, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Andrés Echeverri
- Sección de Reumatología, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Javier Márquez
- Sección de Reumatología, Hospital Pablo Tobón Uribe, Medellín, Colombia
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Rose AM. Anti-neutrophil cytoplasmic antibody-positive vasculitis secondary to therapeutic levamisole. Rheumatology (Oxford) 2020; 59:keaa087. [PMID: 32129859 DOI: 10.1093/rheumatology/keaa087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Indexed: 02/28/2024] Open
Affiliation(s)
- Anna M Rose
- Medical Sciences Division, University of Oxford, Oxford, UK
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40
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Sahoo RR, Agarwal V, Wakhlu A. Drug-induced rheumatic syndromes: the need to be aware. J R Coll Physicians Edinb 2020; 50:8-9. [PMID: 32539028 DOI: 10.4997/jrcpe.2020.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023] Open
Affiliation(s)
- Rasmi Ranjan Sahoo
- Department of Clinical Immunology and Rheumatology, King George's Medical University, Lucknow, India
| | - Vikas Agarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow-226014, India,
| | - Anupam Wakhlu
- Department of Clinical Immunology and Rheumatology, King George's Medical University, Lucknow, India
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Wallace ZS, Stone JH. Personalized Medicine in ANCA-Associated Vasculitis ANCA Specificity as the Guide? Front Immunol 2019; 10:2855. [PMID: 31867013 PMCID: PMC6909331 DOI: 10.3389/fimmu.2019.02855] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 11/20/2019] [Indexed: 11/30/2022] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a small- to medium-vessel necrotizing vasculitis responsible for excess morbidity and mortality (1). The AAVs, which include granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA), are among the most difficult types of vasculitis to treat. Although clinicopathologic disease definitions have been used traditionally to categorize patients into one of these three diagnoses, more recently ANCA specificity for either proteinase 3 (PR3) or myeloperoxidase (MPO) has been advocated for the purpose of disease classification (2). This is because differences in genetics, pathogenesis, risk factors, treatment responses, and outcomes align more closely with PR3- or MPO-ANCA type than with the clinocopathologic diagnosis. Moreover, classifying patients as GPA or MPA can be challenging because biopsies are not obtained routinely in most cases and existing classification systems can provide discrepant classification for the same patient (3). In this review, we address the recent literature supporting the use of ANCA specificity to study and personalize the care of AAV patients (Table 1). We focus particularly on patients with GPA or MPA.
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Affiliation(s)
- Zachary S Wallace
- Clinical Epidemiology Program, Mongan Institute, Boston, MA, United States.,Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Boston, MA, United States.,Massachusetts General Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - John H Stone
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Boston, MA, United States.,Massachusetts General Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
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42
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43
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Cocaine-induced ANCA-associated renal disease: a case-based review. Rheumatol Int 2019; 39:2005-2014. [DOI: 10.1007/s00296-019-04410-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 07/31/2019] [Indexed: 12/26/2022]
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44
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Destructive Upper Airway Disease from Eosinophilic Granulomatosis with Polyangiitis (EGPA): The Very First Case. Case Rep Rheumatol 2019; 2019:6173869. [PMID: 31263619 PMCID: PMC6556304 DOI: 10.1155/2019/6173869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 05/05/2019] [Indexed: 11/18/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a multisystem vasculitic disorder that predominantly affects medium- and small-sized blood vessels. EGPA belongs to a group of vasculitides known as anti-neutrophil cytoplasmic antibody- (ANCA-) associated vasculitis (AAV). Upper airway involvement is seen in all ANCA-associated vasculitides, but destructive upper airway disease has never been reported in patients with EGPA. We report the first case of erosive chondritis and saddle nose deformity in a 50-year-old patient suffering from EGPA.
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Incidentally Diagnosed Alport Syndrome in a Patient with Drug-Induced Vasculitis. Case Rep Nephrol 2019; 2019:8720837. [PMID: 31093390 PMCID: PMC6481119 DOI: 10.1155/2019/8720837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/19/2019] [Accepted: 03/26/2019] [Indexed: 11/17/2022] Open
Abstract
A 53-year-old woman is admitted with a serum creatinine of 16 mg/dl. Seven months earlier, she was diagnosed with heart failure and started on several medications, including Hydralazine. Laboratory studies revealed the presence of dual Anti-Neutrophil Cytoplasmic Antibodies (anti-MPO and anti-PR3), anti-nuclear and anti-histone antibodies. The clinical diagnosis was Drug-Induced ANCA Vasculitis (DIAV). Kidney histology, however, did not reveal crescents, but showed characteristic features of Alport's syndrome.
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Morcos MB, Lood C, Hughes GC. Demographic, Clinical, and Immunologic Correlates among a Cohort of 50 Cocaine Users Demonstrating Antineutrophil Cytoplasmic Antibodies. J Rheumatol 2019; 46:1151-1156. [PMID: 31092720 DOI: 10.3899/jrheum.180771] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Cocaine/levamisole-associated autoimmunity syndrome (CLAAS) is a poorly understood form of drug-induced autoimmunity. Our goals were to better characterize the spectrum of clinical and immunologic features of CLAAS, to identify demographic risk factors, and to generate new hypotheses regarding pathogenesis. METHODS CLAAS subjects were identified between 2001 and 2015 at the University of Washington Medical Center, Harborview Medical Center, and affiliated clinics in Seattle, Washington, USA. Demographic, clinical, and immunologic variables were collected and correlated using contingency and logistic regression analyses. We used similar analyses to compare CLAAS subjects with all individuals exhibiting antineutrophil cytoplasmic antibodies (ANCA+) or cocaine use (Cocaine+) in an associated deidentified clinical data repository. RESULTS We identified 50 CLAAS subjects. Compared to all Cocaine+ individuals (n = 2740), CLAAS subjects were more likely to be female and less likely to self-identify as black/African American. CLAAS subjects showed several ANCA patterns, including anti-MPO (myeloperoxidase)/anti-PR3 (proteinase 3) dual reactivity, a finding that appears to be specific to CLAAS. Hematologic, renal, and skin abnormalities were most frequently reported, including neutropenia and skin purpura. Finally, we observed strong, independent associations between the cytoplasmic ANCA (C-ANCA) pattern and mortality. CONCLUSION We identify sex and race as important risk modifiers in the developing CLAAS among cocaine users. The development of C-ANCA was associated with increased mortality. Moreover, we confirm the enriched presence of anti-MPO/anti-PR3 dual reactivity in CLAAS, further supporting the diagnostic utility of this feature.
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Affiliation(s)
- Meredith B Morcos
- From the University of Washington Department of Medicine, Division of Rheumatology, Seattle, Washington, USA. .,M.B. Morcos, MD, University of Washington Department of Medicine, Division of Rheumatology; C. Lood, PhD, University of Washington Department of Medicine, Division of Rheumatology; G.C. Hughes, MD, University of Washington Department of Medicine, Division of Rheumatology.
| | - Christian Lood
- From the University of Washington Department of Medicine, Division of Rheumatology, Seattle, Washington, USA.,M.B. Morcos, MD, University of Washington Department of Medicine, Division of Rheumatology; C. Lood, PhD, University of Washington Department of Medicine, Division of Rheumatology; G.C. Hughes, MD, University of Washington Department of Medicine, Division of Rheumatology
| | - Grant C Hughes
- From the University of Washington Department of Medicine, Division of Rheumatology, Seattle, Washington, USA.,M.B. Morcos, MD, University of Washington Department of Medicine, Division of Rheumatology; C. Lood, PhD, University of Washington Department of Medicine, Division of Rheumatology; G.C. Hughes, MD, University of Washington Department of Medicine, Division of Rheumatology
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47
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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.
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48
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Abstract
Systemic and localized vasculitis affects the skin and subcutis, due to large vascular beds and hemodynamic factors, such as stasis in lower extremities, and environmental influences, as occur in cold exposure. Initial cutaneous manifestations of vasculitides include diverse and dynamic patterns of discoloration, swelling, hemorrhage, and necrosis. One-half of affected patients present with localized, self-limited disease to the skin without any known trigger or associated systemic disease, known as idiopathic cutaneous leukocytoclastic vasculitis. Skin biopsy and dermatopathology contribute relevant information; however, they require correlation with clinical history, physical examination, and laboratory findings to reach an accurate diagnosis.
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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 10016, USA; School of Public Health, City University of New York, New York, NY, USA.
| | - Andrew Carlson
- Department of Pathology, Division of Dermatology and Dermatopathology, Albany Medical College, 43 New Scotland Avenue, MC-81, Albany, NY 12208, USA
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49
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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]
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50
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Mesa-Álvarez L, Peón Currás G, Flórez Á. Widespread Erythematous and Bullous Plaques Associated With Nasolabial Fold Ulceration: Answer. Am J Dermatopathol 2019; 41:237-238. [PMID: 30801345 DOI: 10.1097/dad.0000000000001051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Laura Mesa-Álvarez
- Dermatology Department, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
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