S3054 Cocaine-Induced Vasculitis

Abstract

INTRODUCTION: Once used as a chemotherapeutic with 5-fluorouracil in the treatment of advanced colon cancer, levamisole is now making news in the general population for its use in recreational drugs.The medication was banned by the FDA due to its adverse effects which include neutropenia, skin necrosis, and agranulocytosis. It now remains on the market as an antihelminth for livestock. Since 2008, the drug has made its way back into the limelight as an additive agent in cocaine with significant systemic manifestations complicating its prompt diagnosis. CASE DESCRIPTION/METHODS: 52 year-old female with bipolar disorder presented after a ground level fall. Per family, patient had ongoing weakness for several weeks. On the morning of the fall, patient reported that she was seated on the side of the chair when she suddenly lost her balance. She denied any symptoms leading up to her fall and any loss of consciousness, confusion, and loss of bowel or bladder control after. She was found to have extensive dry, gangrenous tissue or bilateral lower extremities and on the dorsal aspect of her left hand. Patient reported that her skin findings began as a generalized body rash about 9 months ago. She completed a 7-day course of prednisone. The rash appeared to subside at first but later became blister-like. She was referred to a dermatologist but was unable to follow up. In the months leading up to her fall, patient reported eruptions of these blisters with darkening of her skin along her extremities. On admission, she had extensive foul smelling necrosis of her extremities with intermittent, sharp pain at rest and with movement. She denied any travel, bites, gardening, and saltwater exposure, but admitted to daily oral cocaine use. She underwent extensive debridement. Biopsy was negative for neoplasia or granulomatous inflammation. Serology was positive for p-anca. She was discharged after counseling against cocaine use with high dose prednisone and mycophenolate mofetil for 2 months. She was followed up outpatient to monitor ESR and CRP levels and showed remarkable improvement in her overall strength and appearance with multidisciplinary support. DISCUSSION: Dry gangrene results from occlusion of arterial blood flow to the extremities and can be caused by thromboangitis obliterans, raynaud’s, trauma, and some aggressive forms of vasculitis. Levamisole-induced vasculitis has been associated with elevations in p-ANCA which may delay its diagnosis. Discontinuation of cocaine alone can result in near complete recovery.Figure 1.: After 1 month.Figure 2.: On day of presentation.Figure 3.: After 2 months.