ANCA Associated Vasculitis Secondary to Levamisole-Adultered Cocaine with Associated Membranous Nephropathy: A Case Series

Abstract

Background: Cocaine is a risk factor for acute kidney injury and chronic kidney disease with progression to end-stage renal disease. Levamisole is an adulterant that is added to cocaine to enhance its euphoric effects. Levamisole-adulterated cocaine (LAC) is associated with the distinct clinical syndromes of agranulocytosis, leukocytoclastic vasculitis, cocaine-induced midline destructive lesions (CIMDL), and ANCA-associated vasculitis (AAV) with pauci-immune necrotizing glomerulonephritis. Methods: We reviewed all cases of AAV secondary to LAC at our institution. Results: We report 3 cases of AAV secondary to LAC and associated membranous nephropathy (MN). The first and second cases are concurrent AAV secondary to LAC and associated MN while the third case involves the development of MN after AAV secondary to LAC. Conclusions: Clinicians should be aware of this novel association of LAC with MN.

Levamisole adulterated cocaine associated ANCA vasculitis: review of literature and update on pathogenesis

“…In cases with organ failure, immunosuppression is the mainstay of treatment. We identified 22 cases of levamisole-associated biopsy-proven pauciimmune glomerulonephritis, including 18 mentioned in the review of Neel et al, and several other recent cases [3][4][5]7,[9][10][11][12][13][14][15][16][17][18][19][20][21]. 21 of 22 cases received immunosuppressive therapy; the remaining patient was anuric and received urgent HD.…”

Adulterants in crack cocaine in Brazil

“…20 Because of its immunomodulatory effects, levamisole has been used to treat immune-mediated and inflammatory disorders, such as rheumatoid arthritis, nephritic syndrome, inflammatory bowel disease, aphthous ulcers and colon cancer. [21][22][23][24] As a result, one of the most severe consequences of the adulteration of cocaine with levamisole is leukoencephalopathy. Xu et al speculated that levamisole could cause acute and recurrent white matter lesions.…”

Antineutrophil cytoplasmic antibodies negative levamisole‐induced leukocytoclastic vasculitis: a presumed case and literature review

“…When available, the specificity of p‐ANCA may be helpful in differentiating LIV from other vasculitides, as atypical antibody targets like human neutrophilic enolase (HNE) rather than myeloperoxidase (MPO) are more frequently associated with cocaine exposure. Additional laboratory findings in LIV may include neutropenia, leukopenia, agranulocytosis, hypocomplementemia, C‐reactive protein, and elevated sedimentation rate …”

“…As part of the innate immune system, this represents a mechanism to bind and kill extracellular microbes independent of phagocytic uptake. 21,22 A study by Lood and Hughes 22 14,20,21,[28][29][30] There are no established criteria for levamisole-induced vasculitis/vasculopathy, and the diagnosis is based on clinical suspicion and that of exclusion. 14,27,31 Hence, a judicious history and physical exam remain a clinician's strongest diagnostic tool.…”