Purple ear and retiform purpura

Abstract

A 40-year-old female was presented to the hospital with bluish discoloration of ears, joint pain and skin rash. The past medical history was significant for hepatitis C infection. She was enrolled in a methadone program for heroin addiction, and she reported that she had been using crack cocaine for 10 years. Physical examination revealed purplish discoloration of both right (Fig. 1a) and left ears involving the external pinnae and helixes. The tip of the nose had a prominent necrotic purpura, and the right cheek showed a tender purpuric plaque (Fig. 1b). There were multiple large painful confluent retiform purpura over the lower extremities (Fig. 1c). Multiple joint tenderness without joint effusion was noted. Significant laboratory findings included leucopenia with a WBC count of 2 300 cells/mm (normal, 4 400–11 000 cells/mm) with a normal complete metabolic panel. Hepatitis C polymerase chain reaction (PCR) assay showed undetectable viral load and serum cryoglobulin level was normal. The antinuclear antibody (ANA), anti-Smith antibody and perinuclear antineutrophil cytoplasmic antibody (p-ANCA) were positive. Results of further work-up for infectious, hematologic and rheumatologic disorders were negative. Urine toxicology screening was positive for cocaine. The clinical picture was highly suggestive of levamisole-contaminated cocaineinduced cutaneous vasculitis. A punch biopsy of cutaneous purpura was performed, and showed small-vessel vasculitis with perivascular neutrophilic infiltrates (arrows) with dermal hemorrhages (asterisks), which were compatible with features of leukocytoclastic vasculitis (Fig. 1d, e). The patient was treated with systemic corticosteroids, and the leucopenia resolved and the cutaneous purpura improved significantly (Fig. 1f). Our patient presented with the clinical, biochemical and histologic features consistent with levamisole toxicity. According to the United States Centers for Disease Control and Prevention (CDC), 70 % of cocaine supply in the United States is adulterated with levamisole, which is being cut into the cocaine before it is smuggled into the United States [1]. Levamisole is an immunomodulatory agent, and has been used for the treatment of pediatric nephrotic syndrome, rheumatoid arthritis and colon cancer [1, 2]. However, it was withdrawn from the United States due to the risk of agranulocytosis. It is currently used in the United States as an anti-helminthic medication in the veterinary field [2, 3]. The reasons for addition of levamisole to cocaine are thought to be increasing the total weight of the cocaine due to its physical similarity to cocaine, and prolonging the cocaine-induced euphoria by potentiating the nicotinic acetylcholinergic effects [1–3]. Although levamisole is a more expensive additive agent, the major attractive incentive for using levamisole as a cocaine Z. Min (&) Department of Medicine, Division of Infectious Diseases, Allegheny General Hospital, 420 East North Avenue, East Wing, Suite 407, Pittsburgh, PA 15212, USA e-mail: zmin@wpahs.org