COCAINE OR YOUR LIMBS?

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Cocaine adulterated with levamisole has become more prevalent increasing for the last twenty years. Vasculitis induced by levimasole has been increasing in prevalence. We present a case of a 51-year-old male with known cocaine abuse who presented with recurrent large purpuric lesions on face, arms, and legs that required aggressive surgical debridement. CASE PRESENTATION: 51-year-old male with history of cocaine abuse was admitted for hemoptysis. He had purpuric lesions of bilateral cheeks, left ear, right upper extremity, and bilateral lower extremities upon admission. He had a similar illness two years before, but the lesions were limited to bilateral upper extremities. He required skin grafting of bilateral forearms and shoulders at that time. He developed worsening purpuric lesions of cheeks, upper extremities which blistered and necrosed in a very short period of time. His lower extremity purpuric lesions extended from the ankles to mid-thigh bilaterally. His urine drug screen was positive for cocaine only and his ANA was positive. Rheumatoid factor, ESR, CRP were elevated. Complement 3 levels were decreased but the remainder of the autoimmune evaluation was negative. CBC with differential showed leukopenia with ANC 1322. Skin biopsy was consistent with levamisole induced vasculitis. He was begun on Prednisone with a very slow taper. He subsequently noted improvement of skin lesions and was discharged with wound care management. He returned one month later with worsening purpuric lesions, he again tested positive for cocaine, diagnosed with necrotizing vasculitis and then required debridement of the lower extremities with multiple skin grafts. DISCUSSION: Cocaine adulterated with levamisole is becoming an increasing problem in the United States with more than 70% of cocaine testing positive for levamisole leading to increased case reports of Levamisole induced vasculitis. This diagnosis should be suspected in a patient who is uses cocaine presents with purpuric rash or skin necrosis with associated agranulocytosis, neutropenia, and positive ANA or ANCA. CONCLUSIONS: Cocaine using patients who present with purpuric lesion or skin necrosis should have a high index of suspicion for levamisole associated vasculitis, prompt treatment with steroids and wound care is required to prevent loss of limbs. Reference #1: Souied O, Baydoun H, Ghandour Z, Mobarakai N. Levamisole-contaminated cocaine: an emergent cause of vasculitis and skin necrosis. Case Rep Med. 2014;2014:434717. Reference #2: Jin Q, Kant S, Alhariri J, Geetha D. Levamisole adulterated cocaine associated ANCA vasculitis: review of literature and update on pathogenesis. J Community Hosp Intern Med Perspect. 2018;8(6):339–344. Published 2018 Dec 11. DISCLOSURES: No relevant relationships by Haneen Mallah, source=Web Response No relevant relationships by Brandon Rogers, source=Web Response No relevant relationships by Jasmine Sekhon, source=Web Response No relevant relationships by Divya Vangipuram, source=Web Response