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.
Highlights
According to July 2009 estimates, 69% of the cocaine seized by the US Drug Enforcement Administration (DEA) is adulterated with levamisole [1,2]
Levamisole is a veterinary antihelminthic agent that has recently been linked to vasculitis and neutropenia in people with cocaine use [3,4]
We describe a cocaine user with levamisole-induced necrosis of the skin, soft tissue, and cartilage resulting in nasal amputation, earlobe necrosis, and bilateral above-knee amputation (AKA)
Summary
According to July 2009 estimates, 69% of the cocaine seized by the US Drug Enforcement Administration (DEA) is adulterated with levamisole [1,2]. Laboratory investigations revealed leukopenia with a white blood cell count (WBC) of 2,600 cells/μL, neutropenia with an absolute neutrophil count (ANC) of 900 cells/μL, an elevated erythrocyte sedimentation rate (ESR) of 47 mm/hour, presence of lupus anticoagulant, low complement component 3 (C3) (85 mg/dL), a normal coagulation profile, absence of antinuclear antibody (ANA), absence of cardiolipin antibody, presence of perinuclear anti-neutrophil cytoplasmic antibody (p-ANCA) against myeloperoxidase (MPO), and absence of antiproteinase 3 (anti-PR3) antibody Her urine toxicology screen was positive for cocaine, and gas chromatography–mass spectrometry (GCMS) was positive for levamisole. Large lower extremity bullae ruptured, leading to wound infection and septicemia with Staphylococcus aureus, Enterobacter cloacae, and Morganella morganii, which were treated with broad-spectrum antibiotics At this point, skin involvement was estimated to be 35% of the total body surface area, and the patient was managed in a burn unit. The patient was readmitted with new painful necrotic lesions on the amputated stumps (Figure 6) She admitted to cocaine use three days prior to this admission. Her pain and lesions improved significantly, and she was discharged home with a plan to follow up with the hospital’s plastic surgery service for nose reconstruction
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