A novel cutaneous vasculitis syndrome induced by levamisole-contaminated cocaine

Abstract

In order to describe the clinical and serologic features of a cutaneous vasculitis due to cocaine contaminated with the adulterant levamisole, we report four new cases of this syndrome along with 12 previously reported cases identified through a PubMed Literature search (1964 to March 2011). Of the 16 patients described, the average age was 43, with a female predominance (81% of patients). Over half of patients had involvement of the earlobes, and the rash frequently affected the extremities in a "retiform" pattern. Leukopenia or neutropenia was reported in 56% of patients. Ninety-three percent were anti-neutrophil cytoplasmic antibody positive, and 63% tested positive for anti-phospholipid antibodies. The predominant pattern seen on histopathological examination of the skin was small vessel vasculitis and/or a thrombotic vasculopathy. Treatment in these patients varied widely, with several patients showing improvement or resolution of the rash without specific therapy following cessation of illicit drug use. This new cutaneous vasculitis syndrome can be recognized by its characteristic rash and skin pathology, together with leukopenia and autoantibody production. Certain clinical features can be attributed to the adulterant levamisole, though cocaine as well may play a role in its pathogenesis.

Levamisole-Contaminated Cocaine Use in HIV-Infected and Uninfected Unstably Housed Women

“…While neutropenia has been cited as a concern in case reports of persons seeking treatment for conditions linked to levamisole, 9,14,16,35,36 we did not find significant differences in neutrophil count by cocaine and levamisole status (Table 2). Furthermore, adjusted models suggested mediation of cocaine/ levamisole effects on white blood cell count by lymphocyte count, but not by neutrophil count (Table 3).…”

“…[14][15][16] Furthermore, women have higher rates of stimulant dependence, more severe forms of stimulant addiction and lower rates of treatment than men, [20][21][22][23] which may result in differential levamisole exposure. In addition, sex differences in both the pharmacokinetics of HIV medication 24 and the natural course of HIV disease 25 have been identified.…”

“…Harmful effects include agranulocytosis, necrotizing vasculitis, fixed drug eruptions and pruritic rashes, [7][8][9][10][11][12][13] and levamisole-toxicity cases are disproportionately described among women. [14][15][16] Accurately identifying levamisoleinduced health complications is essential for discontinuing exposure, and preventing unnecessary use of other treatments with potentially strong side effects such as immunosuppressive therapy. 17 While the number of case reports appearing in the medical literature has increased, the population-level clinical and socioeconomic correlates of levamisole-contaminated cocaine use are not well established.…”

Cutaneous Vasculopathy Associated with Levamisole-Adulterated Cocaine

“…In users of cocaine contaminated with levamisole, a cutaneous vasculopathy syndrome has recently emerged and is characterized by a distinctive purpuric rash with a predilection for the ears, ANCA positivity, and leukopenia. [1][2][3] Levamisole, an antihelminthic with immunomodulatory properties, was previously used for the treatment of autoimmune disorders, pediatric nephritic syndrome, and cancer. It was withdrawn from the market in 2000 due to its adverse side effect profile, specifically agranulocytosis.…”

Severe ANCA Associated Vasculitis in the Setting of Cocaine Abuse: A Case Report

“…The natural history of the cutaneous manifestations of levamisole induced AAV is spontaneous resolution after the substance is withdrawn; though immunologic markers may persist for up to 14 months [7]. In cocaine-induced systemic vasculitis, patients may be positive for PR3-ANCA, MPO-ANCA and/or the combination PR3-ANCA and MPO-ANCA may be found [8].…”