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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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Ruffer N, Krusche M, Holl-Ulrich K, Kötter I, Lötscher F. [Cocaine-induced vasculitis and mimics of vasculitis]. Z Rheumatol 2023; 82:606-614. [PMID: 35612660 PMCID: PMC10495486 DOI: 10.1007/s00393-022-01217-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2022] [Indexed: 11/29/2022]
Abstract
Cocaine is a psychotropic tropane alkaloid and stimulant drug. Nasal insufflation of cocaine powder is a common route of administration. In Germany, cocaine is frequently adulterated with levamisole, an anthelminthic drug with immunomodulatory effects. Both substances are linked to various autoimmune conditions. Cocaine-induced midline destructive lesions cause a progressive destruction of osteocartilaginous structures within the upper respiratory tract and can mimic localized granulomatosis with polyangiitis. In addition, systemic vasculitis due to cocaine and levamisole has been reported. Differentiation of these conditions from primary vasculitis can be challenging because antineutrophil cytoplasmic antibodies (ANCA) are commonly detected. Early diagnosis of these conditions is crucial as clinical improvement is closely related to drug cessation.
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Affiliation(s)
- Nikolas Ruffer
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland.
- Sektion Rheumatologie und entzündliche Systemerkrankungen, III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Martin Krusche
- Sektion Rheumatologie und entzündliche Systemerkrankungen, III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Konstanze Holl-Ulrich
- Konsultations- und Referenzzentrum für Vaskulitis-Diagnostik, Pathologie-Hamburg, Labor Lademannbogen MVZ GmbH, Hamburg, Deutschland
| | - Ina Kötter
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
- Sektion Rheumatologie und entzündliche Systemerkrankungen, III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Fabian Lötscher
- Universitätsklinik für Rheumatologie, Immunologie und Allergologie, Inselspital, Universitätsspital Bern, Bern, Schweiz
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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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Ortiz-Seller A, Hernández-Pons A, Pascual EV, Comín Pérez A, Dolz Gaitón R, Albert-Fort M. Severe Cocaine-Induced Midline Destructive Lesions (CIMDL) Leading to Orbital Apex Syndrome and Peripheral Ulcerative Keratitis. Ocul Immunol Inflamm 2022; 30:1956-1960. [PMID: 33872101 DOI: 10.1080/09273948.2021.1906913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE To describe a case of cocaine-induced midline destructive lesions (CIMDL) associated with ocular autoimmune disease.Methods: Observational case report. RESULTS A 45-year-old man with history of chronic osteolytic sinusitis due to cocaine abuse presented with sudden vision loss in right eye. Ophthalmic examination revealed fixed right mydriasis with extraocular movements limitation and optic disc swelling. Computed tomography showed an orbital infiltrating mass. The diagnosis of orbital-apex syndrome secondary to CIMDL was established. Steroids and antibiotics therapy were started without vision improvement. At 6-months follow-up, a corneal ulcer with characteristics of peripheral ulcerative keratitis (PUK) was evidenced, coinciding with an upper respiratory bacterial infection. CONCLUSIONS CIMDL and PUK share common pathogenic pathways, with implication of autoimmune factors and exposure to infective antigens. We hypothesized that chronic cocaine use, along with persistent bacterial infection, could have triggered an inflammatory reaction, which contributed to CIMDL development and the appearance of PUK.
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Affiliation(s)
- Amparo Ortiz-Seller
- Department of Ophthalmology, Hospital Universitari Doctor Peset, Valencia, Spain
| | | | - Elia Valls Pascual
- Department of Rheumatology, Hospital Universitari Doctor Peset, Valencia, Spain
| | - Alberto Comín Pérez
- Department of Ophthalmology, Hospital Universitari Doctor Peset, Valencia, Spain
| | - Raquel Dolz Gaitón
- Department of Pathology, Hospital Universitari Doctor Peset, Valencia, Spain
| | - Mara Albert-Fort
- Department of Ophthalmology, Hospital Universitari Doctor Peset, Valencia, Spain
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Martínez-Gómez M, Ramírez-Ospina JA, Ruiz-Restrepo JD, Velásquez-Lopera MM. Pyoderma gangrenosum associated to the use of cocaine/levamisole. Series of three cases and literature review. An Bras Dermatol 2021; 96:188-195. [PMID: 33640188 PMCID: PMC8007549 DOI: 10.1016/j.abd.2020.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 06/25/2020] [Indexed: 11/24/2022] Open
Abstract
Pyoderma gangrenosum associated to the use of cocaine/levamisole is a rare condition associated to their consumption. Cocaine use is frequent in Colombia, and the substance is contaminated with levamisole, an anthelmintic that increases the psychotropic effects and enhances its side effects. We present three clinical cases of patients with ulcerated lesions, in which the diagnosis was pyoderma gangrenosum secondary to the use of cocaine contaminated with levamisole. This called the attention of the health staff to investigate the abuse of substances in gangrenous pyoderma and also evidence that the interruption of consumption was the basis of management.
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Affiliation(s)
- Manuel Martínez-Gómez
- Service of Dermatology, Department of Internal Medicine, Faculty of Medicine, University of Antioquia and San Vicente Fundación Hospital, Medellín, Colombia.
| | - Joan Andrés Ramírez-Ospina
- Service of Dermatology, Department of Internal Medicine, Faculty of Medicine, University of Antioquia and San Vicente Fundación Hospital, Medellín, Colombia
| | - Juan David Ruiz-Restrepo
- Service of Dermatology, Department of Internal Medicine, Faculty of Medicine, University of Antioquia and San Vicente Fundación Hospital, Medellín, Colombia
| | - Margarita María Velásquez-Lopera
- Service of Dermatology, Department of Internal Medicine, Faculty of Medicine, University of Antioquia and San Vicente Fundación Hospital, Medellín, Colombia
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7
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Pustular Eruption After Cocaine Use: Answer. Am J Dermatopathol 2018; 40:859-860. [PMID: 30339565 DOI: 10.1097/dad.0000000000000989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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8
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Reilkoff R, Stephenson L. Fulminant hepatic failure in the setting of progressive ANCA-associated vasculitis associated with a rare alpha-1 antitrypsin phenotype, 'PiEE'. BMJ Case Rep 2018; 2018:bcr-2017-222036. [PMID: 29592975 PMCID: PMC5878378 DOI: 10.1136/bcr-2017-222036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Abnormalities in alpha-1 antitrypsin (AAT) proteins are risk factors for human disease. While the most common is AAT deficiency, a genetic disorder associated with chronic obstructive pulmonary disease, additional disorders associated with AAT abnormalities are increasingly recognised. We describe a middle-aged woman who presented with fulminant hepatic and multiorgan failure. Evaluation revealed the patient to have a rare AAT phenotype PiEE. Her clinical presentation was consistent with antineutrophilic cytoplasmic antibody-associated vasculitis, and her history suggested features of panniculitis. This is the first description of this rare homozygous AAT phenotype and possible disease associations with the ’E' protein. Given that abnormal AAT are under-recognised, and that new mutations and phenotypes continue to be identified, we will need to expand on our knowledge base and report clinical manifestations associated with these abnormal phenotypes.
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Affiliation(s)
- Ronald Reilkoff
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA.,Critical Care, Fairview Southdale Hospital, Edina, Minnesota, USA
| | - Laurel Stephenson
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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9
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Cocaine and ANCA associated vasculitis-like syndromes – A case series. Autoimmun Rev 2018; 17:73-77. [DOI: 10.1016/j.autrev.2017.11.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 10/02/2017] [Indexed: 11/19/2022]
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10
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Ghias AAP, Brine P. Vanishing vasculitis: a case of acute necrotic skin findings without pathologic features of vasculitis from adulterated cocaine. J Community Hosp Intern Med Perspect 2017; 7:321-324. [PMID: 29147477 PMCID: PMC5676965 DOI: 10.1080/20009666.2017.1374109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 08/28/2017] [Indexed: 11/27/2022] Open
Abstract
While the usage of illicit drugs in itself carries significant health risks and associated toxicities, drugs that are adulterated to give them volume, alter their psychogenic properties, and make them cheaper to produce are to be considered even more dangerous. Cocaine is one of them, and it is now most commonly being adulterated with levamisole. We report a case of a 37-year-old female with the chief complaint of painful skin lesions and wounds on both of her upper and lower extremities for three weeks duration. She was tested positive for cocaine and had classical purpuric, ecchymotic, and necrotic patches on both ears, which are pathognomonic. She also had multiple wounds in extremities. The cocaine–levamisole related syndrome comprises a set of immunological abnormalities, out of which, ANCA positivity is the most important one. Our patient was ANCA positive. Regarding pathological findings in cocaine adulterated with levamisole syndrome, this can range from the classic finding of leukocytoclastic vasculitis of small vessels to occlusive vascular disease without true vasculitis. Our case’s biopsy showed no vasculitis, and this is why it is important to highlight that cocaine can also cause a pseudo-vasculitic picture. The other possibility that we entertained was that of pyoderma gangrenosum as the skin finding in levamisole-contaminated cocaine, and the lesion was consistent in appearance. Recently, there have been a few case reports of pyoderma gangrenosum from adulterated cocaine with levamisole, where skin findings were consistent with pyoderma gangrenosum; however, serological findings rather favored levamisole vasculopathy or vasculitis. Therefore, we should familiarize ourselves with the multitude of pathological and skin findings that adulterated cocaine can cause and, finally, make ourselves aware that the classical pathological finding of vasculitis in such cases is not always seen.
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Affiliation(s)
| | - Patrick Brine
- Internal Medicine Residency Program, St. Elizabeth Youngstown Hospital, Youngstown, OH, USA
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11
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Levamisole/Cocaine Induced Systemic Vasculitis and Immune Complex Glomerulonephritis. Case Rep Nephrol 2015; 2015:372413. [PMID: 26290761 PMCID: PMC4531184 DOI: 10.1155/2015/372413] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 07/14/2015] [Indexed: 11/17/2022] Open
Abstract
Levamisole is an antihelminthic and immunomodulator medication that was banned by the USFDA in 1998. It has been increasingly used to adulterate cocaine due to its psychotropic effects and morphological properties. Adverse reactions including cutaneous vasculitis, thrombocytopenia, and agranulocytosis have been well described. Despite systemic vasculitis in this setting, renal involvement is uncommon. We report here a case of ANCA positive systemic vasculitis with biopsy proven immune complex mediated glomerulonephritis likely secondary to levamisole/cocaine. A 40-year-old Caucasian male with no past medical history presented with 3-week history of fatigue, skin rash, joint pains, painful oral lesions, oliguria, hematuria, worsening dyspnea on exertion, and progressive lower extremity edema. He had a history of regular tobacco and cocaine use. Lab testing revealed severe anemia, marked azotemia, deranged electrolytes, and 4.7 gm proteinuria. Rheumatologic testing revealed hypocomplementemia, borderline ANA, myeloperoxidase antibody, and positive atypical p-ANCA. Infectious and other autoimmune workup was negative. Kidney biopsy was consistent with immune mediated glomerulonephritis and showed mesangial proliferation and immune complex deposition consisting of IgG, IgM, and complement. High dose corticosteroids and discontinuing cocaine use resulted in marked improvement in rash, mucocutaneous lesions, and arthritis. There was no renal recovery and he remained hemodialysis dependent.
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12
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Nolan AL, Jen KY. Pathologic manifestations of levamisole-adulterated cocaine exposure. Diagn Pathol 2015; 10:48. [PMID: 25943359 PMCID: PMC4419488 DOI: 10.1186/s13000-015-0279-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 04/16/2015] [Indexed: 11/30/2022] Open
Abstract
ᅟ Rheumatic manifestations of cocaine have been well described, but more recently, a dramatic increase in the levamisole-adulterated cocaine supply in the United States has disclosed unique pathologic consequences that are distinct from pure cocaine use. Most notably, patients show skin lesions and renal dysfunction in the setting of extremely high perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA). Unexpectedly, antibodies to myeloperoxidase, the typical target of p-ANCA, are relatively low if at all present. This discrepancy is due to the fact that p-ANCA seen in association with levamisole-adulterated cocaine exposure is often directed against atypical p-ANCA-associated antigens within the neutrophil granules such as human neutrophil elastase, lactoferrin, and cathepsin G. Biopsies of the skin lesions reveal leukocytoclastic vasculitis often involving both superficial and deep dermal vessels. Renal injury most typically manifests as crescentic and necrotizing pauci-immune glomerulonephritis. In this review, the manifestations of levamisole-adulterated cocaine-induced vasculitis are discussed with an emphasis on the typical histomorphologic findings seen on biopsy. Virtual Slides The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1764738711370019.
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Affiliation(s)
- Amber L Nolan
- Department of Pathology, University of California San Francisco, 513 Parnassus Avenue, Box 0102, San Francisco, CA, 94143, USA.
| | - Kuang-Yu Jen
- Department of Pathology, University of California San Francisco, 513 Parnassus Avenue, Box 0102, San Francisco, CA, 94143, USA.
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13
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Fowler AH, Majithia V. Ultimate mimicry: methamphetamine-induced pseudovasculitis. Am J Med 2015; 128:364-6. [PMID: 25498165 DOI: 10.1016/j.amjmed.2014.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 12/01/2014] [Accepted: 12/01/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Amanda H Fowler
- Division of Rheumatology, Department of Medicine, University of Mississippi Medical Center, Jackson.
| | - Vikas Majithia
- Division of Rheumatology, Department of Medicine, University of Mississippi Medical Center, Jackson; Division of Rheumatology, Department of Medicine, GV (Sonny) Montgomery Veterans Affairs Medical Center, Jackson
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Abstract
BACKGROUND Nasal membranes may be injured by immune disease, infection, trauma, or cocaine. Destruction of the septum, vault and floor lining, external skin, upper lip, and adjacent structures follows. METHODS Lining injuries caused by cocaine, Wegener granulomatosis, primary syphilis, leishmaniasis, septorhinoplasty, septal cancer excision and irradiation, corrosive inhalation, and foreign body and iatrogenic intubation injury were reviewed. The site and degree of injury were correlated with presentation and anatomical and functional abnormality. RESULTS Damage may be isolated to the septum, creating a septal fistula with loss of dorsal and tip support and modest collapse of the dorsum and tip with columellar retraction, or the injury may extend onto the vaults and floor, leading to circumferential scar contracture and severe nasal shortening and lip retraction. Progressive disease, infection, or iatrogenic injury increases soft-tissue damage, causing external skin contraction or full-thickness necrosis. CONCLUSIONS Repair is determined by site, depth of injury, and clinical deformity--not cause. Lining necrosis and subsequent scar contraction, rather than structural compromise of the septum, are the primary causes of the severe deformity. If vault and floor lining injury is minimal, central support alone will restore dorsal and tip projection. Extensive loss requires release of scar contracture and replacement of the vault and floor lining with composite grafts, a microvascular flap, or hinge-over lining flaps, depending on the site and extent of injury. If the external skin is destroyed by scar or a full-thickness loss, a staged forehead flap will be required to resurface the nose.
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Carlson AQ, Tuot DS, Jen KY, Butcher B, Graf J, Sam R, Imboden JB. Pauci-immune glomerulonephritis in individuals with disease associated with levamisole-adulterated cocaine: a series of 4 cases. Medicine (Baltimore) 2014; 93:290-297. [PMID: 25398064 PMCID: PMC4602417 DOI: 10.1097/md.0000000000000090] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Exposure to levamisole-adulterated cocaine can induce a distinct clinical syndrome characterized by retiform purpura and/or agranulocytosis accompanied by an unusual constellation of serologic abnormalities including antiphospholipid antibodies, lupus anticoagulants, and very high titers of antineutrophil cytoplasmic antibodies. Two recent case reports suggest that levamisole-adulterated cocaine may also lead to renal disease in the form of pauci-immune glomerulonephritis. To explore this possibility, we reviewed cases of pauci-immune glomerulonephritis between 2010 and 2012 at an inner city safety net hospital where the prevalence of levamisole in the cocaine supply is known to be high. We identified 3 female patients and 1 male patient who had biopsy-proven pauci-immune glomerulonephritis, used cocaine, and had serologic abnormalities characteristic of levamisole-induced autoimmunity. Each also had some other form of clinical disease known to be associated with levamisole, either neutropenia or cutaneous manifestations. One patient had diffuse alveolar hemorrhage. Three of the 4 patients were treated with short courses of prednisone and cyclophosphamide, 2 of whom experienced stable long-term improvement in their renal function despite ongoing cocaine use. The remaining 2 patients developed end-stage renal disease and became dialysis-dependent. This report supports emerging concern of more wide spread organ toxicity associated with the use of levamisole-adulterated cocaine.
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Affiliation(s)
- Adam Q Carlson
- Divisions of Rheumatology (AQC, JG, JBI) and Nephrology (DST, BB, RS), Department of Medicine, San Francisco General Hospital and University of California, San Francisco; and Department of Pathology (KYJ), University of California, San Francisco, California
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García Pérez MR, Ortiz-González VL, Betancourt M, Mercado R. Cocaine-induced vasculitis: is this a new trend? Open Access Rheumatol 2013; 5:77-80. [PMID: 27790026 PMCID: PMC5074789 DOI: 10.2147/oarrr.s51524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Cocaine-induced vasculitis is a rare complication found in drug abusers. It occurs due to cocaine adulterated with levamisole. Levamisole was once used as a chemotherapy and immunomodulator for different conditions. One of the side effects of this medication is necrotizing vasculitis which has been reported in the US and Puerto Rico. Here we present another case of cocaine induced vasculitis in Puerto Rico. We describe a 43-year-old female with past medical history of bronchial asthma, migraine, and crack smoking who presented to the emergency room due to blood in her urine for 5 days. She also reported fever, chills, and fatigue. At the physical exam she had a right knee ulcer with swelling erythema, warmth, and pain. Also, she had retiform purpuric plaque lesions in her ears, bilaterally. Eroded plaques with elevated borders at left foot and finger dorsum were also present. Laboratory workup was positive for cocaine. The patient showed leucopenia and microcytic anemia with a normal absolute neutrophil count in her cell blood count. Blood cultures, urine cultures, and ulcer cultures were negative. Urinalysis was positive for proteinuria and hematuria. Also, the patient had positive perinuclear anti-neutrophil cytoplasmic antibody, cytoplasmic anti-neutrophil cytoplasmic antibody, and antinuclear antibody tests and elastase specificity. She showed negative anticardiolipin and lupus anticoagulant antibodies. Her complement levels were decreased. The punch biopsy of her ear showed superficial thrombosis of superficial vascular plexus with perivascular lymphocytic infiltrates and deeper sections showed epidermal necrosis and necrotizing vasculitis. She was started on a high dose of steroids, but could not complete the treatment because she escaped from the hospital before finishing her treatment.
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Affiliation(s)
| | | | | | - Rogelio Mercado
- Department of Dermatology, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
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Hennings C, Miller J. Illicit drugs: What dermatologists need to know. J Am Acad Dermatol 2013; 69:135-42. [DOI: 10.1016/j.jaad.2012.12.968] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Revised: 12/11/2012] [Accepted: 12/16/2012] [Indexed: 10/27/2022]
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18
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Rubin K. The manifestation of cocaine-induced midline destructive lesion in bone tissue and its identification in human skeletal remains. Forensic Sci Int 2013; 231:408.e1-11. [PMID: 23706264 DOI: 10.1016/j.forsciint.2013.04.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 02/16/2013] [Accepted: 04/21/2013] [Indexed: 11/18/2022]
Abstract
Cocaine-induced midline destructive lesion (CIMDL) is a condition that may arise in response to chronic insufflation ("snorting") of cocaine. It is clinically diagnosed when the nasal septum, lateral nasal walls, and/or hard palate show signs of destruction in association with cocaine use. Although its true incidence is unknown, CIMDL is not an uncommon clinical finding amongst intranasal cocaine abusers and is likely to be encountered by forensic anthropologists and medical examiners working worldwide. Given the preponderance of drug abusers amongst the subjects of forensic casework, the ability to diagnose CIMDL in dry bone may provide crucial insight into an investigation and even help confirm an individual identification. This paper aims to make practicing forensic anthropologists aware of CIMDL. Through the analysis of existing clinical literature, patient CT scans, and histology sections, it works toward the establishment of formal diagnostic criteria for identifying CIMDL in human skeletal remains. Lytic destruction regularly involves the vomer and frequently extends to the perpendicular plate of the ethmoid, the palatal process of the maxillae or the palatine bones, and the inferior nasal conchae. The middle nasal conchae, medial walls of the maxillary sinuses, ethmoid sinuses, and cribriform plate are often damaged. Destruction may also implicate the superior nasal conchae, the orbit, and the sphenoid. Bones affected by CIMDL may contain necrotic lesions or may be absent entirely. Lesions show minimal, if any, signs of repair. The author proposes that this lack of new bone formation may be mediated by potentially elevated leptin levels in cocaine abusers and CIMDL patients and may be the key to differentiating CIMDL from other lytic processes of the midface.
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Affiliation(s)
- Katie Rubin
- University of Pennsylvania, Department of Anthropology, University Museum, Room 325, 3260 South Street, Philadelphia, PA 19104, USA.
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Abstract
PURPOSE OF REVIEW Cocaine use is associated with several rheumatic syndromes. This review summarizes these clinical manifestations and highlights recent developments linked to levamisole-adulterated cocaine. RECENT FINDINGS Cocaine use has been linked to several distinctive syndromes that can be difficult to distinguish from idiopathic rheumatic diseases. These disorders can range in severity from purely cosmetic damage to organ and/or life-threatening disease that includes sinonasal destruction and vasculitis. Many of these illnesses are associated with antineutrophil cytoplasmic antibodies (cytoplasmic, perinuclear and atypical perinuclear patterns). With the recent introduction of levamisole as a cocaine adulterant, a newly reported syndrome has emerged that is associated with neutropenia, retiform purpura with cutaneous necrosis and autoantibodies consisting of high-titre perinuclear antineutrophil cytoplasmic antibodies (p-ANCAs) with specificities for 'atypical' antigens. SUMMARY Cocaine use is associated with clinical syndromes that closely mimic other primary rheumatic diseases. Given the high prevalence of cocaine use and its adulteration with levamisole, clinicians should be familiar with these rheumatic manifestations in order to avoid misdiagnosis and unnecessary treatment with potentially toxic therapies.
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Abstract
BACKGROUND Levamisole has recently been implicated as a cause of cutaneous vasculopathy in cocaine abusers. The objective of this study was to describe this relatively new entity by reviewing published cases identified through a literature search. METHODS Published reports identified through a search of PubMed database (from 1964 to November 2011) were reviewed to record clinical, serological and pathologic findings. RESULTS A cohort of 32 patients had a mean age of 44 ± 9 years with a female predominance (75%). Rash predominately affected lower extremities (87.5%), followed by face (78%) and ears (69%) and typically presented as purpuric plaques, which were seen in a retiform pattern in 16 (50%) and had central necrosis in 11 patients (34%). Leukopenia and neutropenia were found in 20 patients (63%). Antinuclear cytoplasmic antibody (ANCA) was positive in 30 patients (94%); p-ANCA in 28 patients (87.5%), c-ANCA in 19 (59%) and both in 17 patients (53%). Skin biopsy results were available for 29 patients: 14 (48%) had pure thrombotic vasculopathy, 4 (14%) had pure small vessel vasculitis and 11 (38%) had evidence of both. Treatment information was available for 30 patients. Only supportive care was given to 11 patients (37%), steroids to 16 (53%) and surgical treatment for 5 (17%). Clinical course of lesions was available for 24 patients. Rash resolved in 11 patients (46%) and improved in 13 (54%). During median follow-up of 21 days (range, 7-270 days), 10 of 22 patients had recurrences related to cocaine use. CONCLUSION Levamisole-induced cutaneous vasculopathy in cocaine users is characterized by a female predominance, a retiform purpuric rash with a predilection for lower extremities, autoantibody production, leukopenia and/or neutropenia and recurrences with future cocaine use.
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Abstract
We report a case of cutaneous vasculopathy associated with the use of levamisole-adulterated cocaine. This recently described clinical entity is characterized by a purpuric rash with a predilection for the ears, leukopenia, and anti-neutrophilic cytoplasmic antibody (ANCA) positivity. It is estimated that more than 70% of the current United States cocaine supply is contaminated with levamisole. Levamisole is a widely available, inexpensive, white powder used as a "cutting agent" in cocaine to expand volume and increase profits. It may also increase the euphoric and stimulatory effects of cocaine by increasing brain dopamine levels and producing amphetamine-like metabolites. Our patient exhibited a characteristic rash with involvement of the ears, leukopenia, and cocaine metabolites were detected in serum and urine. The presence of levamisole was confirmed in the urine utilizing gas chromatography-mass spectrometry. ANCA positivity was also present. Punch biopsy of the skin demonstrated vascular thrombosis and necrosis without true vasculitis. We review the literature for reported cases of cocaine-levamisole cutaneous vasculopathy syndrome, highlight the salient immunologic abnormalities, and contrast the features of this entity with idiopathic systemic vasculitis.
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Affiliation(s)
- Huy Tran
- Internal Medicine Residency Program, Department of Medicine, St. Elizabeth Health Center, Youngstown, Ohio, USA
| | - Debbie Tan
- Internal Medicine Residency Program, Department of Medicine, St. Elizabeth Health Center, Youngstown, Ohio, USA
| | - Thomas P. Marnejon
- Internal Medicine Residency Program, Department of Medicine, St. Elizabeth Health Center, Youngstown, Ohio, USA
- Department of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, USA
- Corresponding Author: Thomas Marnejon, DO Department of Medicine St. Elizabeth Health Center 1044 Belmont Avenue Youngstown, OH 44501 Tel: (330) 480-3344 Fax: (330) 480-3777
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Abstract
The prevalence of cocaine-induced pseudovasculitis (CIP) causing cutaneous destruction is increasing, and plastic surgeons need to be aware of this condition because they are a part of the multidisciplinary treatment team. Differentiation of CIP from a true autoimmune vasculitis can be exceedingly challenging, and misdiagnosis with ensuing treatment may be fatal. This article is a succinct review of CIP, guided by a clinical case of 30% total body surface area skin necrosis, to familiarize the reader with this syndrome. Diagnostic aids include history of cocaine use, localized disease manifestation to skin or mucosa, discordance of antineutrophil cytoplasmic antibody and target antibody patterns typical for true vasculitis, and testing for antihuman neutrophil elastase and levamisole. Treatment is primarily supportive, and wound care, with regard to dressings and surgery, is a cross between to that of burns and meningococcemia patients.
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Gulati S, Donato AA. Lupus anticoagulant and ANCA associated thrombotic vasculopathy due to cocaine contaminated with levamisole: a case report and review of the literature. J Thromb Thrombolysis 2012; 34:7-10. [PMID: 22437653 DOI: 10.1007/s11239-012-0711-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
A 2010 US report recently detected the presence of levamisole in greater than 77 % of seized cocaine samples. A syndrome of retiform purpura, often involving ears and flanks, with vasculopathy or vasculitis on biopsy, associated with anti-nuclear cytoplasmic antibodies as well as antiphospholipid antibodies, previously associated with therapeutic use of levamisole has now re-emerged, and is associated with cocaine adulterated with levamisole. Patients with this unusual constellation of signs and laboratory findings should be questioned about exposure to cocaine.
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Affiliation(s)
- Shuchi Gulati
- Department of Internal Medicine, The Reading Hospital and Medical Center, 6th Avenue and Spruce Street, West Reading, PA 19611, USA.
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Freyer CW, Peters M. Palpable purpura complicated by streptococcal toxic shock syndrome resulting in limb necrosis and amputation: a case of levamisole and cocaine coingestion. Pharmacotherapy 2012; 32:e17-23. [PMID: 22392427 DOI: 10.1002/phar.1012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Palpable purpura resulting from cocaine and levamisole coingestion has been reported with increasing frequency over the last several years as distribution of this drug combination becomes more universal. Toxicity from ingestion of this dangerous combination is difficult to diagnose due to the multitude of possible clinical presentations, variety of possible adulterants, and elusive nature of levamisole given its short half-life and limited availability of detection methods. Levamisole is a chemotherapeutic and immunomodulatory agent currently marketed as a veterinary anthelmintic. We describe the case of a 48-year-old woman admitted to our intensive care unit with a diagnosis of streptococcal toxic shock syndrome (STSS), confirmed from fluid taken from an elbow lesion that grew Streptococcus pyogenes. She was noted to have bullae of the elbow and diffuse purpura with necrotic centers covering a large portion of her body (trunk, legs, arms, back, toes, fingers, and tip of nose). On further evaluation, she was found to have ingested levamisole-tainted cocaine. The patient's complications related to either cocaine and levamisole coingestion or STSS included thrombocytopenia, acute renal failure, and limb necrosis. Thrombocytopenia gradually improved upon treatment with prednisone, and acute renal failure improved with intravenous fluid resuscitation; however, she subsequently required several appendage amputations due to severe gangrene. Clinicians must have high suspicion for ingestion of this drug combination and request prompt testing of urine samples for levamisole if a patient who admits to illicit drug use presents with purpuric or necrotic skin lesions.
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Affiliation(s)
- Craig W Freyer
- Department of Pharmacy, Henry Ford Hospital, Detroit, Michigan, USA.
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Arora NP, Jain T, Bhanot R, Natesan SK. Levamisole-induced leukocytoclastic vasculitis and neutropenia in a patient with cocaine use: an extensive case with necrosis of skin, soft tissue, and cartilage. Addict Sci Clin Pract 2012. [PMID: 23186390 PMCID: PMC3509389 DOI: 10.1186/1940-0640-7-19] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Levamisole-induced vasculitis is a relatively new entity in people who use cocaine. We describe a 44-year-old woman with a history of cocaine use who presented with a complaint of a painful rash of 2-3 month’s duration on her extremities, cheeks, nose, and earlobes. She had not experienced fever, weight loss, alopecia, dry eyes, oral ulcers, photosensitivity, or arthralgia. Examination revealed tender purpuric eruptions with central necrosis on her nose, cheeks, earlobes, and extremities. Laboratory investigations revealed neutropenia, an elevated erythrocyte sedimentation rate (ESR), presence of lupus anticoagulant, low complement component 3 (C3), and presence of perinuclear anti-neutrophil cytoplasmic antibody (p-ANCA). A urine toxicology screen was positive for cocaine, and gas chromatography–mass spectrometry was positive for levamisole. Skin biopsy showed leukocytoclastic vasculitis and small vessel thrombosis. Necrotic lesions of the nose led to its self-amputation. Large bullae on the lower extremities ruptured, leading to wound infection and extensive necrosis that required multiple surgical debridements. When necrosis progressed despite debridement, bilateral above-knee amputation of the legs was performed. Once new lesions stopped appearing, the patient was discharged home. Two months later, she had a recurrence related to cocaine use. To the best of our knowledge, this is only the second reported case of levamisole-induced vasculitis that required above-knee amputation.
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Affiliation(s)
- Natasha Purai Arora
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit Medical Center, 4201 Saint Antoine Street, Detroit, 48201 MI, USA.
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Endonasal surgery after cocaine abuse: safe at any interval? Case Rep Otolaryngol 2012; 2012:823470. [PMID: 22953124 PMCID: PMC3420621 DOI: 10.1155/2012/823470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 06/08/2012] [Indexed: 11/17/2022] Open
Abstract
Objective. We report a case of poor healing after endonasal surgery for nasal septal perforation ten years after cocaine abuse was ended. Method. The clinical findings are presented. Results. A 35-year-old man presented with a small nasal septal perforation caused by cocaine abuse. He had stopped using it ten years previously so surgery was considered safe. The perforation was surgically closed using an endonasal approach. The perforation, however, recurred, the incision healing delayed, and a saddle deformity developed. Conclusion. The effects of cocaine abuse seem to persist causing poor healing after nasal surgery. Prosthetic treatment should be the primary choice. Caution should be employed when considering surgery even in small perforations due to cocaine abuse even many years after the abuse was terminated.
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Levamisole-induced vasculopathy: a report of 2 cases and a novel histopathologic finding. Am J Dermatopathol 2012; 34:208-13. [PMID: 22094232 DOI: 10.1097/dad.0b013e31821cc0bf] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although cocaine-induced pseudovasculitis and urticarial vasculitis have been reported in the past, levamisole-induced vasculopathy with ecchymosis and necrosis, termed here LIVEN, has only recently been described in association with cocaine use. Levamisole, a veterinary antihelminthic agent used previously as an immunomodulating agent, is present as a "cutting agent" in approximately two-thirds of the cocaine currently entering the United States. Levamisole is believed to potentiate the effects of cocaine and may also be used as a "signature" for tracing its market distribution. Herein, we report 2 cases of LIVEN in patients with histories of chronic cocaine use. In both the cases, a temporal association with neutropenia preceding the eruption was noted. A novel histopathologic finding present only in the second case was the presence of extensive interstitial and perivascular neovascularization. Our 2 cases reaffirm that neutropenia may precede the cutaneous eruption of LIVEN. Case 2 extends the spectrum of histopathologic findings to include the novel phenomenon of neovascularization-hitherto unreported in this entity.
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Khan TA, Cuchacovich R, Espinoza LR, Lata S, Patel NJ, Garcia-Valladares I, Salassi MM, Sanders CV. Vasculopathy, hematological, and immune abnormalities associated with levamisole-contaminated cocaine use. Semin Arthritis Rheum 2012; 41:445-54. [PMID: 22152487 DOI: 10.1016/j.semarthrit.2011.04.010] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 04/27/2011] [Accepted: 04/29/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To report 4 cases of cocaine-related purpura and to review previously reported cases of levamisole, levamisole-contaminated cocaine, and cocaine-induced vasculopathy. METHODS We describe 4 patients suspected of vasculopathy associated with levamisole-tainted cocaine use. A retrospective review of the literature was performed using the PubMed, PubJet, MD consult, and Cochrane review databases. RESULTS Four cases (2 females and 2 males), 46 to 55 years of age, presented with cocaine-related purpura, mainly affecting the ears, neutropenia, and autoantibodies. Skin biopsies revealed a mixed pattern of leukocytoclastic vasculitis and microvascular thrombosis in 2 cases, and pure thrombosis in the third case. The mixed vasculopathic pattern in association with neutropenia, both known adverse effects of levamisole, and levamisole positivity in 2 cases point to this compound as the true etiologic agent in our patients. Eleven cases of levamisole-contaminated cocaine-induced vasculopathy have been described in the English literature. Among these, 10 were females. Age range was 22 to 57 years. Urine levamisole positivity was tested and confirmed in 3 of the 11 cases. The clinical characteristics, laboratory features, histology, treatment, and recovery rates were compared for the published cases of levamisole, levamisole-contaminated cocaine, and cocaine-induced vasculopathy. CONCLUSIONS Adulterated cocaine abuse is an increasingly recognized phenomenon in North America. Levamisole is among the many contaminants that have been detected in seized cocaine throughout North America and Europe. Recent reports described an association between levamisole-tainted cocaine and purpuric skin rash, neutropenia, and the presence of autoantibodies.
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Affiliation(s)
- Tahir A Khan
- Section of Rheumatology, LSU Health Sciences Center, New Orleans, LA, USA
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Abstract
The authors present a case of a 51-year-old male who arrived to the emergency department (ED) with rash and arthralgias. He was not initially forthcoming about all aspects of his history, but ultimately careful clinical evaluation confirmed by laboratory abnormalities revealed the diagnosis. The patient's clinical presentation is given, a discussion of the differential diagnoses is included, and his clinical course is summarized.
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Affiliation(s)
- Melissa A Marinelli
- Department of Emergency Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA.
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Belfonte CD, Shanmugam VK, Kieffer N, Coker S, Boucree S, Kerr G. Levamisole-induced occlusive necrotising vasculitis in cocaine abusers: an unusual cause of skin necrosis and neutropenia. Int Wound J 2012; 10:590-6. [PMID: 22716045 DOI: 10.1111/j.1742-481x.2012.01027.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
We present three cases describing the various skin manifestations of presumed levamisole-contaminated cocaine use. Antibody-mediated vasculitis and neutropenia were consistent findings in these cases and repeat exposure resulted in distinct dermatologic complications. This phenomenon of levamisole-induced vasculitis and neutropenia is being increasingly described and has characteristic wound manifestations that must be recognised and treated early.
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Affiliation(s)
- Cassius D Belfonte
- Division of Cardiology, Howard University Hospital, Washington, DC, USA Division of Rheumatology, Immunology and Allergy, Georgetown University Hospital, Washington, DC, USA Division of Rheumatology, Veterans Affairs Hospital, Washington, DC, USA Department of Internal Medicine, Howard University Hospital, Washington, DC, USA
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Necrotizing peripheral vasculitis/vasculopathy following the use of cocaine laced with levamisole. J Burn Care Res 2012; 33:e6-e11. [PMID: 22138808 DOI: 10.1097/bcr.0b013e318235615a] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The objective of this study was to describe a novel presentation of peripheral vasculitis associated with levamisole-adulterated cocaine. Cocaine abuse is widespread in the United States with 5.3 million people using cocaine in 2008. Over the past decade, drug enforcement officials have noticed the presence of levamisole in confiscated cocaine samples as an adulterant. Known side effects of cocaine-related levamisole ingestion have included agranulocytosis and a cutaneous acral purpura that is histopathologically characterized by a mixture of inflammation (vasculitis) and occlusion (vasculopathy). A 54-year-old man who nasally ingested cocaine laced with levamisole developed widespread necrotic/purpuric skin lesions on approximately 20% of his body with an acral accentuation. These lesions were complicated by multiple areas of sloughing and necrosis. He was initially treated with topical silver sulfadiazine dressing changes but progressed to require debridement and split-thickness skin grafting. Peripheral vasculitis/vasculopathy with severe necrosis resembling Coumadin necrosis is a relatively recently recognized sequelae from levamisole-adulterated cocaine use.
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Cocaine Induced Vasculitis: Have We Found a Culprit? Case Rep Rheumatol 2012; 2012:982361. [PMID: 23346447 PMCID: PMC3546447 DOI: 10.1155/2012/982361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 12/05/2012] [Indexed: 11/18/2022] Open
Abstract
Cocaine abuse is relatively common in our society. To enhance profitability and acceptability of the product, it is not uncommon for illicit drugs to undergo several processes. The Drug Enforcement Agency (DEA) has reported that seventy percent (70%) of cocaine seized at USA borders has been adulterated with levamisole, previously used as chemotherapeutic and immunomodulator for several conditions. Among the side effects of levamisole-adulterated cocaine, necrotizing vasculitis is the more dramatic. We report three cases of necrotizing vasculitis associated with antineutrophils cytoplasmic antibodies (ANCAs) positivity, linked to the use of cocaine. To our knowledge, these are the first cases of cocaine induced vasculitis reported in the Caribbean.
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A case of levamisole-induced systemic vasculitis and cocaine-induced midline destructive lesion: a case report. J Clin Rheumatol 2011; 17:197-200. [PMID: 21617545 DOI: 10.1097/rhu.0b013e31821cb9d5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We describe a case of antineutrophil cytoplasmic antibody-positive vasculitis from levamisole-tainted cocaine with concomitant cocaine-induced midline destructive lesions of the palate and nasal septum. The diagnosis was confirmed after extensive clinical, laboratory, pathologic, and radiographic testing. Timely recognition of this clinical entity is critical to avoid misdiagnosis and unnecessary treatment with potentially harmful cytotoxic agents. Given the high rate of levamisole contamination within the nation's cocaine supply, clinicians should be alerted to this emerging health threat.
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Poon SH, Baliog CR, Sams RN, Robinson-Bostom L, Telang GH, Reginato AM. Syndrome of Cocaine-Levamisole-Induced Cutaneous Vasculitis and Immune-Mediated Leukopenia. Semin Arthritis Rheum 2011; 41:434-44. [DOI: 10.1016/j.semarthrit.2011.05.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2010] [Revised: 05/24/2011] [Accepted: 05/25/2011] [Indexed: 11/13/2022]
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McGrath MM, Isakova T, Rennke HG, Mottola AM, Laliberte KA, Niles JL. Contaminated cocaine and antineutrophil cytoplasmic antibody-associated disease. Clin J Am Soc Nephrol 2011; 6:2799-805. [PMID: 21980179 DOI: 10.2215/cjn.03440411] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Approximately 70% of illicit cocaine consumed in the United States is contaminated with levamisole. Most commonly used as a veterinary antihelminthic agent, levamisole is a known immunomodulating agent. Prolonged use in humans has been associated with cutaneous vasculitis and agranulocytosis. We describe the development of a systemic autoimmune disease associated with antineutrophil cytoplasmic antibodies (ANCA) in cocaine users. This complication appears to be linked to combined cocaine and levamisole exposure. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Cases were identified between March 2009 and November 2010 at Massachusetts General Hospital's ANCA laboratory. Cocaine exposure was identified from patient history in all cases. Medical records were reviewed for clinical presentation and for laboratory and diagnostic evaluation. RESULTS Thirty cases of ANCA positivity associated with cocaine ingestion were identified. All had antimyeloperoxidase antibodies and 50% also had antiproteinase 3 antibodies. Complete clinical and laboratory data were available for 18 patients. Arthralgia (83%) and skin lesions (61%) were the most frequent complaints at presentation. Seventy-two percent of patients reported constitutional symptoms, including fever, night sweats, weight loss, or malaise. Four patients had biopsy-proven vasculitis. Two cases of acute kidney injury and three cases of pulmonary hemorrhage occurred. From the entire cohort of 30, two cases were identified during the first 3 months of our study period and nine cases presented during the last 3 months. CONCLUSIONS We describe an association between the ingestion of levamisole-contaminated cocaine and ANCA-associated systemic autoimmune disease. Our data suggest that this is a potentially life-threatening complication of cocaine use.
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Affiliation(s)
- Martina M McGrath
- Renal Division, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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Milman N, Smith CD. Cutaneous vasculopathy associated with cocaine use. Arthritis Care Res (Hoboken) 2011; 63:1195-202. [DOI: 10.1002/acr.20483] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Gross RL, Brucker J, Bahce-Altuntas A, Abadi MA, Lipoff J, Kotlyar D, Barland P, Putterman C. A novel cutaneous vasculitis syndrome induced by levamisole-contaminated cocaine. Clin Rheumatol 2011; 30:1385-92. [DOI: 10.1007/s10067-011-1805-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2011] [Accepted: 06/13/2011] [Indexed: 10/18/2022]
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Myocbacterium-avium intracellulare associated inflammatory pseudotumor of the anterior nasal cavity. Head Neck Pathol 2011; 5:296-301. [PMID: 21327589 PMCID: PMC3173547 DOI: 10.1007/s12105-011-0248-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2011] [Accepted: 02/03/2011] [Indexed: 10/18/2022]
Abstract
In this case report, we describe an unusual case of mycobacterial associated inflammatory pseudotumor that occurred in a patient with a previous history of cocaine abuse. We discuss inflammatory pseudotumor (IPT) in general and emphasize the rare entity where an associated mycobacterial infection is seen. The histogenesis is not yet completely understood. The lesion can pose challenges for practicing pathologists and a misdiagnosis of malignancy can occur at multiple facets. A discussion about the differential diagnosis and clues to make the distinction is presented. In addition to spindle cell proliferation, the presence of a background of mixed inflammatory cell infiltrate and foamy macrophages are clues to make the diagnosis. In the case of mycobacteria associated IPT, Acid Fast Bacilli (AFB) stains will easily highlight the organisms confirming the diagnosis.
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de la Hera I, Sanz V, Cullen D, Chico R, Petiti G, Villar M, Burgués M, Sanz J, Castellanos M, Zarco O, Ortiz P, Rodríguez-Peralto J, Vanaclocha F. Necrosis of Ears after Use of Cocaine Probably Adulterated with Levamisole. Dermatology 2011; 223:25-8. [DOI: 10.1159/000329436] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 05/07/2011] [Indexed: 11/19/2022] Open
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Walsh NMG, Green PJ, Burlingame RW, Pasternak S, Hanly JG. Cocaine-related retiform purpura: evidence to incriminate the adulterant, levamisole. J Cutan Pathol 2010; 37:1212-9. [PMID: 20738457 DOI: 10.1111/j.1600-0560.2010.01613.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The term 'cocaine-induced pseudovasculitis' was coined to encompass a constellation of clinical and laboratory findings which mimics a systemic vasculitis but lacks confirmatory evidence of vasculitis on biopsy. Antineutrophil cytoplasmic antibodies reacting with human neutrophil elastase (HNE) have been reported to distinguish the cocaine-related syndrome from a true autoimmune vasculitis. Published cases of retiform purpura related to cocaine use are rare and an etiologic role for levamisole, a common adulterant of cocaine, has been postulated. We describe two female patients aged 39 and 49 years with cocaine-related retiform purpura, mainly affecting the legs. The initial clinical and serological profile in case 1 led to a suspicion of anti-phospholipid syndrome and in case 2 to Wegener's granulomatosis with an unexplained associated neutropenia. Skin biopsies revealed a mixed pattern of leukocytoclastic vasculitis and microvascular thrombosis in case 1 and pure microvascular thrombosis in case 2. Identification of anti-HNE antibodies in both patients linked their disease to cocaine. The mixed vasculopathic pattern in case 1 and the associated neutropenia in case 2, both known adverse effects of levamisole, point to this as the true etiologic agent. Urine toxicology shortly after a binge of cocaine use in each case was positive for levamisole.
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Affiliation(s)
- Noreen M G Walsh
- Department of Pathology, Capital District Health Authority and Dalhousie University, 5788 University Avenue, Halifax, Nova Scotia, Canada.
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Hofstede TM, Jacob RF. Diagnostic considerations and prosthetic rehabilitation of a cocaine-induced midline destructive lesion: A clinical report. J Prosthet Dent 2010; 103:1-5. [PMID: 20105673 DOI: 10.1016/s0022-3913(09)00153-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The intranasal inhalation of cocaine has numerous complications. In addition to its systemic effects, cocaine can cause extensive destruction of the osteocartilaginous midline structures of the palate, nose, and sinuses. Without an accurate social and clinical history, a cocaine-induced midline destructive lesion can cause diagnostic difficulties, because its clinical presentation closely mimics other diseases. This clinical report describes an oronasal defect caused by cocaine use, the diagnostic considerations of these lesions, and prosthetic management of the defect.
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Affiliation(s)
- Theresa M Hofstede
- Assistant Professor, Department of Head and Neck Surgery, Section of Oncologic Dentistry and Prosthodontics, The University of Texas M. D. Anderson Cancer Center, Houston, Texas TX 77030-4009, USA.
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Lee BL, Stone JH, Gimbel D, Khosroshahi A. A 44-year-old woman with cutaneous bullae and extensive skin necrosis. Arthritis Care Res (Hoboken) 2010; 62:1805-11. [DOI: 10.1002/acr.20240] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2010] [Accepted: 04/20/2010] [Indexed: 11/10/2022]
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Abstract
Vasculitis often presents a diagnostic challenge as the disease processes may have varied presentations. This article reviews some vasculitis-like "mimics," particularly emphasizing viral and bacterial infections, drug-related disorders, various malignancies, and other autoimmune disorders, all of which may have a similar clinical presentation. This article also highlights recent advances and the importance of accurate diagnosis and therapy.
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Abstract
Chronic rhinosinusitis together with nasal septal perforation with or without pain of the nasal skeleton and without previous trauma or surgery point toward the possible diagnosis of Wegener's granulomatosis. However, nasal biopsy and serologic testing remain inconclusive in many patients. The otolaryngologist's role in this situation is to initiate, in close cooperation with a rheumatologist, therapy with sulfatrimethoprim, as well as with immunosuppressants if necessary. This helps stabilize the symptomatology and may prevent progressive systemic disease.
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Rachapalli SM, Kiely PDW. Cocaine-induced midline destructive lesions mimicking ENT-limited Wegener's granulomatosis. Scand J Rheumatol 2008; 37:477-80. [PMID: 18830903 DOI: 10.1080/03009740802192043] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The prevalence of cocaine use is rising worldwide, with a resultant rise in associated pathology. Regular nasal use can cause cocaine-induced midline destructive lesions (CIMDL), which can be difficult to distinguish from ear, nose, and throat (ENT)-limited Wegener's granulomatosis (WG). Two cocaine users presented with mid-facial pain, epistaxis, and systemic symptoms. Both had nasal septal perforation, necrosis of sinus mucosa, and positive anti-neutrophil cytoplasmic antibodies (ANCA). Histology was inconclusive and treatment with immunosuppressive drugs was commenced. The first patient continued to use cocaine initially, with improvement in her symptoms only on high doses of steroid. Later she stopped cocaine and this plus a switch from cyclophosphamide to mycophenolate mofetil resulted in successful symptom resolution and steroid withdrawal. The second patient denied cocaine use but having only partially responded to high-dose prednisolone and methotrexate, she admitted continued cocaine use and was lost to follow-up. Evaluation of a patient with destructive lesions of the mid-face should include enquiry about intranasal use of cocaine. Localized ENT involvement, inconsistent ANCA pattern, and atypical biopsy findings for WG should be recognized as features of CIMDL. Although cessation of cocaine use is crucial, there may be a role for immunosuppression.
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Affiliation(s)
- S M Rachapalli
- Department of Rheumatology, St George's Healthcare NHS Trust, London, UK
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Castelino FV, Wasfy JH, Collier D. A 36-year-old man with paresthesias and a headache. ACTA ACUST UNITED AC 2008; 59:1358-65. [PMID: 18759310 DOI: 10.1002/art.24008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Flavia V Castelino
- Massachusetts General Hospital, Yawkey Center, Suite 2C-2100, 55 Fruit Street, Boston, MA 02114, USA.
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Brewer JD, Meves A, Bostwick JM, Hamacher KL, Pittelkow MR. Cocaine abuse: dermatologic manifestations and therapeutic approaches. J Am Acad Dermatol 2008; 59:483-7. [PMID: 18467002 DOI: 10.1016/j.jaad.2008.03.040] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2007] [Revised: 03/12/2008] [Accepted: 03/25/2008] [Indexed: 11/18/2022]
Abstract
Cocaine affects the cutaneous system and other organ systems. Cocaine use is associated with vasculitides, infectious complications, and numerous dermatologic conditions. It has been associated with formication (ie, tactile hallucinations of insects crawling underneath the skin), which leads to delusions of parasitosis and other psychosis-related dermatologic disorders. When a patient presents to a dermatology clinic with chronic skin lesions, a vague medical history, negative findings from previous evaluations, labile affect, and delusional behavior, drug screening should be performed to identify possible cocaine use.
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Affiliation(s)
- Jerry D Brewer
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota 55905, USA.
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