LEVAMISOLE-INDUCED VASCULITIS COMPLICATED BY PRESEPTAL CELLULITIS

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Approximately 0.6% of the US adult population use cocaine each month. Cocaine use is accountable for over 33% of all drug-related ED visits. There have been several rare but serious complications described in literature. We present a case of cocaine-induced vasculitis complicated by preseptal cellulitis. CASE PRESENTATION: A 50 year-old woman with a history of cocaine use, presented with altered mental status. On examination, patient was drowsy but arousable and mildly hypotensive. Necrotic skin with eschar was noted on her face (Figure 1). Labs revealed leukocytosis, acute kidney injury (AKI), and metabolic acidosis. CK was 16,000; ESR 29, CRP 424, and procalcitonin 17. Urine was positive for cocaine and amphetamines. CT head revealed edema and tissue stranding extending into the left preseptal orbit. Based on history and examination, a diagnosis was made of levamisole-induced vasculitis. Patient was admitted to the ICU and treated with IV fluids, broad spectrum antibiotics for preseptal cellulitis, and bicarbonate infusion for cocaine-induced rhabdomyolysis. Her hypotension resolved and her AKI improved. Blood cultures grew Prevotella oralis. Further work up revealed positive c-ANCA. HIV, HBV, HCV were negative; c3, c4 levels normal; p-ANCA, cryoglobulin, ANA, and anti-cardiolipin antibodies were negative. Biopsy of the facial lesion revealed sparse perivascular and periadnexal dermatitis with neutrophils and lymphocytes, indicating dermal hypersensitivity and early vasculitic changes. PAS and DIF were negative for fungal elements and immunoreactant deposition, respectively. Her facial lesions were treated conservatively and improved. DISCUSSION: This patient’s presentation is consistent with vasculitis induced by the cocaine adulterant, levamisole. Levamisole is an anti-helminthic medication with veterinarian-restricted use. It is known to cause vasculitis. The possible mechanism is via mimicking thymopoietin, which may potentiate macrophage activity, enhance T-cell function, and stimulate antibody production. Levamisole has been described to increase the potency of recreational cocaine, and is frequently used as a cutting agent. As of 2011, over 80% of cocaine seized in the US contained levamisole. While most individuals do not experience negative effects attributed to levamisole, there have been reports of ANCA-positive vasculitis. While p-ANCA is the most commonly found high-titer autoantibody, levamisole can also cause elevated ANA, anti-human neutrophil elastase, and c-ANCA. Biopsy usually reveals small vessel thrombosis and perivascular mononuclear infiltration with few neutrophils. CONCLUSIONS: In conclusion, levamisole is a clinically relevant adulterant that must be considered in ANCA-positive vasculitis in cocaine users. Reference #1: National Institute on Drug Abuse. “Nationwide Trends.” NIDA, 2015. Reference #2: Abdul-Karim, R et al. Proceedings (BaylorMedical Center). 2013;26: 163. Reference #3: Pieterse E et al. Pathogenesis of cocaine-induced vasculitis. Rheumatology 2017; 56: 503. https://doi.org/10.1093/rheumatology/kew381. DISCLOSURES: No relevant relationships by Debapriya Datta, source=Web Response No relevant relationships by Jose Soriano, source=Web Response No relevant relationships by Katherine Stettmeier, source=Web Response