Levamisole-Induced Vasculitis: A Characteristic Cutaneous Vasculitis Associated With Levamisole-Adulterated Cocaine

Cocaine-Induced Plasma Cell Orificial "Dermatomucositis": A More Accurate Descriptive Term for a Clearly Dermatological Entity

ABSTRACT

Although the involvement of the nasal passages and nasal septum in cocaine users has been known for decades, a new presentation affecting the nostrils and upper lip with an inflamed appearance has recently been documented. The authors who identified this presentation termed it "cocaine-related plasma cell mucositis" due to the abundance of plasma cells in the infiltrate. In this article, we present a second case and emphasize the dermal involvement of the lip, leading us to consider the condition as a genuine dermatomucositis.

Periorbital Pyoderma Gangrenosum Associated With a Cocaine-Induced Midline Destructive Lesion: Case Report and Review of the Literature

A 72-year-old woman with a history of chronic cocaine use presented 9 months after a dog bite with a large facial ulceration and absent sinonasal structures. Biopsies were negative for infectious, vasculitic, or neoplastic pathologies. The patient was lost to follow up for 15 months and returned with a significantly larger lesion despite abstinence from cocaine. Additional inflammatory and infectious workup was negative. Intravenous steroids were administered with clinical improvement. Therefore, she was diagnosed with pyoderma gangrenosum and cocaine-induced midline destructive lesion due to cocaine/levamisole. Pyoderma gangrenosum is a rare dermatologic condition that uncommonly involves the eye and ocular adnexa. Diagnosis involves clinical examination, response to steroids, exclusion of infectious or autoimmune conditions, and identifying potential triggers including cocaine/levamisole. This report highlights a rare presentation of periorbital pyoderma gangrenosum causing cicatricial ectropion associated with concomitant cocaine-induced midline destructive lesion and reviews important aspects of clinical manifestations, diagnosis, and management of pyoderma gangrenosum and cocaine/levamisole autoimmune phenomenon.

The effects of alcohol and illicit drug use on the skin

Early identification of cutaneous manifestations of alcohol and illicit drug use can aid in the diagnosis and management of these uses, as well as their sequelae. In addition, the effects of alcohol and illicit drug use on the skin can result in significant morbidity. Alcohol misuse can present with jaundice, pruritus, pigmentary alterations, urticaria, hair and nail changes, and oral changes. It is also a risk factor for skin cancer and infections. Vascular disturbances associated with alcohol misuse include telangiectasias, palmar erythema, caput medusae, and flushing. Diseases related to alcohol misuse include nutritional deficiencies, porphyria cutanea tarda, psoriasis, seborrheic dermatitis, nummular dermatitis, and rosacea. Other conditions seen in alcohol misuse include Dupuytren contracture, Peyronie disease, and pancreatitis. Dermatologists should also be aware of hepatotoxic medications that are commonly prescribed for skin diseases so as to avoid initiating hepatoxicity in patients who use alcohol. Illicit drug use can manifest with cutaneous fibrosis, scarring, granulomas, ulceration, pruritus, infections, cocaine-levamisole-induced vasculitis, tooth decay, and oral disease. By recognizing the cutaneous stigmata of alcohol and illicit drug use, dermatologists can aid in the identification and treatment of patients suffering from these addictions.

Simultaneous multifocal intracranial haemorrhage (ICH) and subarachnoid haemorrhage (SAH) in the setting of long-term cocaine usage

A 45-year-old Caucasian man was admitted to hospital following a collapse at home. On admission, this patient was noted to have a Glasgow Coma Scale (GCS) Score of 9 out of 15, fever and tachypnoea. The patient was identified to have bilateral limb weakness, predominately on the left side, with associated dysphagia. Radiological imaging demonstrated bilateral multifocal intracranial haemorrhage and subarachnoid haemorrhage. Neurosurgical input was sought; the outcome of this was a decision to manage the patient conservatively, without surgical intervention. Of note, his urine drug testing revealed a positive result for a cocktail of drugs including cocaine, benzoylecgonine (cocaine metabolite), methadone, heroin, norbuprenorphine and benzodiazepine. Throughout the admission, the patient was monitored in an intensive care setting. The patient received support with feeding, speech and mobilisation. The patients' GCS improved throughout the admission. Following a 30-day admission, the patient walked home.

A case series and literature review on patients with rhinological complications secondary to the use of cocaine and levamisole

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.

Cocaine Use and Levamisole-Induced Vasculitis: A Multiple Case Study

BACKGROUND

Levamisole is an immunomodulatory medication previously used to treat rheumatoid arthritis and some types of cancers; it was banned for use in humans in 2000 owing to its harmful side effects. Use of levamisole-laced cocaine is associated with a life-threatening syndrome characterized by a necrotizing purpuric rash leading to tissue destruction and necrotic wounds. This Clinical Challenges article summarizes our experience with the care of 2 adult women diagnosed with levamisole-related vasculitis.

CASE

Case 1 is a 46-year-old woman who presented with joint pain in her hands and legs, along with bilateral ear pain, swelling, and bleeding. She was initially diagnosed with vasculitis and possible systemic lupus erythematosus. She experienced multiple recurrences and exacerbation of her condition over a period of months. She was ultimately diagnosed with levamisole-related vasculitis from recurrent cocaine use resulting in bilateral above the knee amputations. The second case is a 50-year-old woman who presented to our emergency department with redness and swelling of her bilateral lower extremities. She developed blisters and pustules that rapidly evolved into abscesses and red lesions over the course of several months. Her wounds also deteriorated despite topical therapy that occurred in a context of recurring use of cocaine.

CONCLUSIONS

Our experience with these cases suggests that WOC nurses should consider levamisole-induced vasculitis in all patients presenting with unexplained vasculitis-type lesions, and particularly when these lesions occur in the context of known or suspected use of illicit substances such as cocaine. Given the absence of clinical guidelines for this increasingly prevalent condition, we recommend wound care based on principles of moist wound healing, combined with judicious use of therapies with antimicrobial activity and nonadherent dressings to reduce pain. Finally, we strongly recommend that care of these patients occurs as one part of a multidisciplinary care approach that focuses on cessation of the use of cocaine and all other illicit substances.

Spectrum of acute kidney injury associated with cocaine use: report of three cases

BACKGROUND

The consequences of cocaine use are multisystemic, such as, for instance, renal failure, hepatotoxicity and pulmonary toxicity, with renal alterations being the focus of the present study. The use of substances that modify the base composition of cocaine (or adulterants) aiming to potentiate its effects also has an impact on these manifestations. The present study aims to report three cases with different diagnosis of acute kidney injury related to cocaine use.

CASE PRESENTATION

Case 01 - A 30-year-old female patient, who regularly used cocaine, started to have lower-limb edema, which showed a progressive and ascending evolution, affecting the face a few days later, associated with an isolated febrile episode and oligoanuria. The presence of cytoplasmic antineutrophil cytoplasmic antibodies (C-ANCA) was verified: reactive 1:80, with renal biopsy compatible with rapidly progressive glomerulonephritis (RPGN). Case 02 - A 34-year-old female patient, with difficult-to-control hypertension and a frequent user of cocaine, showed generalized sudden edema together with diffuse and progressive pruritus associated with oliguria, fever, nausea, and vomiting. Schistocyte screening was positive, with negative direct Coombs test, and negative serologies for hepatitis B, C and HIV, as well as negative anti-double-stranded DNA, Anti-SSA and Anti-SSB. The renal biopsy was compatible with thrombotic microangiopathy, associated with moderate interstitial fibrosis and acute tubular necrosis Case 03 - A 25-year-old male patient who had been a cocaine user for 5 years had a sudden onset of generalized disabling myalgia (especially in the lower limbs) associated with recent frontotemporal headache, palpitation, dizziness, and a non-measured febrile episode; the patient had used cocaine at the night before symptom onset. CPK was 1731 U/L.The final probable diagnosis was AKI secondary to cocaine-induced rhabdomyolysis.

CONCLUSIONS

In conclusion basically, 05 etiologies of acute kidney injury should always be remembered: rhabdomyolysis, thrombotic microangiopathy, vasculitis, acute interstitial nephritis and renal infarction. Emphasis should be given to rhabdomyolysis due to its higher prevalence. Considering the increasing rates of cocaine use, especially with the use of adulterating substances, these pathologies will likely be increasingly prevalent.

Levamisole-Induced Vasculitis in the Lower Extremities: A Case Report

BACKGROUND

Since 2006 there have been increased reports of severe agranulocytosis and vasculitis associated with levamisole use. Historically, levamisole was an immunomodulatory agent used in various cancer treatments in the United States. Currently the drug is used as an antihelminthic veterinary medication, but it is also used as an additive in freebase cocaine. There are multiple reports of levamisole-induced vasculitis in the head and neck but limited reported cases in the lower extremities. This article describes a 60-year-old woman who presented to the emergency department with multiple painful lower-extremity ulcerations.

RESULTS

Radiographs, laboratory studies, and punch biopsy were performed. Physical examination findings and laboratory results were negative for signs of infection. Treatment included local wound care and education on cocaine cessation, and the patient was transferred to a skilled nursing facility. Her continued use of cocaine, however, prevented her ulcers from healing.

CONCLUSIONS

Local wound care and cocaine cessation is the optimal treatment for levamisole-induced lesions. With the increase in the number of patients with levamisole-induced vasculitis, podiatric physicians and surgeons would benefit from the immediate identification of these ulcerations, as their appearance alone can be distinct and pathognomonic. Early identification of levamisole-induced ulcers is important for favorable treatment outcomes. A complete medical and social history is necessary for physicians to treat these lesions with local wound care and provide therapy for patients with addictions.

DARK Classics in Chemical Neuroscience: Aminorex Analogues

Aminorex (5-phenyl-4,5-dihydro-1,3-oxazol-2-amine) and 4-methylaminorex (4-methyl-5-phenyl-4,5-dihydro-1,3-oxazol-2-amine) are psychostimulants that have long been listed in Schedules IV and I of the UN Convention on Psychotropic Substances of 1971. However, a range of psychoactive analogues exist that are not internationally controlled and therefore often classified as new psychoactive substances (NPS). Aminorex analogues encompass failed pharmaceuticals that reemerged as drugs of abuse, and newly synthesized substances that were solely designed for recreational use by clandestine chemists. NPS, sometimes also referred to as "designer drugs" in alignment with a phenomenon arising in the early 1980s, serve as alternatives to controlled drugs. Aminorex and its derivatives interact with monoaminergic neurotransmission by interfering with the function of monoamine transporters. Hence, these compounds share pharmacological and neurochemical similarities with amphetamines and cocaine. The consumption of aminorex, 4-methylaminorex and 4,4'-dimethylaminorex (4-methyl-5-(4-methylphenyl)-4,5-dihydro-1,3-oxazol-2-amine) has been associated with adverse events including death, bestowing an inglorious fame on aminorex-derived drugs. In this Review, a historical background is presented, as well as an account of the pharmacodynamic and pharmacokinetic properties of aminorex and various analogues. Light is shed on their misuse as drug adulterants of well-established drugs on the market. This Review not only provides a detailed overview of an abused substance-class, but also emphasizes the darkest aspect of the NPS market, i.e., deleterious side effects that arise from the ingestion of certain NPS, as knowledge of the pharmacology, the potency, or the identity of the active ingredients remains obscure to NPS users.

Levamisole-Adulterated Cocaine Leading to Fatal Vasculitis: A Case Report

Cocaine is often "cut" with various additives to increase the profitability of the drug. One of the most common additives on today's market is levamisole, an anthelmintic medication used to destroy and expel parasitic worms in animals. The use of levamisole-contaminated cocaine can result in agranulocytosis and vasculitis (inflammation and constriction of small blood vessels). The resulting clotting and decrease in peripheral blood flow lead to cutaneous lesions, particularly on the ears, face, hands, and feet, and in severe cases can cause generalized tissue necrosis throughout the entire body. Treatment is generally supportive, and symptoms typically abate with complete cessation of cocaine use. However, symptoms may recur with subsequent cocaine use and, as this case illustrates, severe neutropenia and extensive vasculitis may lead to overwhelming sepsis and death.

Inflammatory Dermatopathology for General Surgical Pathologists

Owing to the wide variety and complexity of inflammatory skin diseases, inflammatory dermatopathology can be a challenging topic for dermatopathologists and general surgical pathologists alike. Following a basic tissue reaction pattern approach, this article reviews the most common and important entities of each pattern, with emphasis on differential diagnosis, diagnostic pitfalls, and appropriate workup when indicated. A few dermatologic emergencies are also discussed.

Vanishing vasculitis: a case of acute necrotic skin findings without pathologic features of vasculitis from adulterated cocaine

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.

Necrotizing and crescentic glomerulonephritis with membranous nephropathy in a patient exposed to levamisole-adulterated cocaine

Levamisole is an antihelminthic agent widely used as an adulterant of illicit cocaine recently implicated as a cause of antineutrophil cytoplasmic antibody (ANCA)–associated microscopic polyangiitis in cocaine abusers. An isolated case of membranous nephropathy (MN) associated with levamisole exposure has also been reported. We report the first case, to our knowledge, of a patient with both microscopic polyangiitis manifest as a pauci-immune necrotizing and crescentic glomerulonephritis and concurrent MN in the setting of chronic cocaine abuse and presumed levamisole exposure, raising the hypothesis that levamisole was the causative agent in the development of this rare dual glomerulopathy.