Characteristic purpura of the ears, vasculitis, and neutropenia–a potential public health epidemic associated with levamisole-adulterated cocaine

Abstract

Background Dermatologists at the University of California, San Francisco recently reported two patients in the online Journal of the American Academy of Dermatology with purpura presumably induced by levamisole in contaminated cocaine. Levamisole-induced vasculitis and neutropenia has been reported elsewhere in the United States and Canada. Up to 70% of cocaine in the United States could be contaminated. Objective We sought to describe similar cases of vasculitis associated with cocaine use. Methods This is a retrospective case series. Results We report 6 remarkably similar patients seen over just the past few months with retiform purpura on the body and tender purpuric eruptions, necrosis, and eschars of the ears after cocaine use in New York and California. All of these patients had positive perinuclear antineutrophil cytoplasmic antibody values and 3 of the 6 also had an associated neutropenia. Direct immunofluorescence studies suggested an immune complex–mediated vasculitis. Limitations This case series is descriptive in nature and, because testing is not easily performed, we did not test for levamisole in the serum or blood to prove this is the causative agent. Conclusion It appears the use of cocaine is associated with the peculiar clinical findings of ear purpura, retiform purpura of the trunk, and neutropenia. We believe this case series may represent the tip of the iceberg as a looming public health problem caused by levamisole. Although the direct causal relationship may be difficult to establish, the astute dermatologist or primary care physician should be able to recognize the characteristic skin lesions and should be wary of the potential development of agranulocytosis. (J Am Acad Dermatol 2011;65:722-5.)

Levamisole-Induced Vasculitis

“…Leukopenia can occur in 50% to 60% of cases (3) and can fi rst develop after as long as 12 months of continuous use (5). Agranulocytosis has also been reported in patients with cocaine/levamisole abuse (6).…”

Suspected Infective Endocarditis Finally Turned Out to Be Levamisole-Induced Vasculitis: A Case Report and Review of Literature

“…Firstly, it inhibits monoamine oxidase and catechol-O-methyltransferase activity resulting in prolonging the action of catecholamine in the neuronal synapse and increasing the reuptake-inhibition effect of cocaine. Levamisole also enhances euphoric and addictive properties of cocaine by increasing dopamine [6]. Levamisole-induced vasculitis syndrome presents with typical findings of vasculopathic purpuric rash involving mainly the ears but can involve nose, cheeks and extremities diffusely [5,7].…”

Levamisole-Adulterated Cocaine: A Case Series

“…Histopathologic patterns often include some degree of thrombosis, leukocytoclastic vasculitis, or both, [2][3][4][5][6]13 making biopsy useful in narrowing the differential diagnosis. Urinary detection of levamisole is a valuable tool as well.…”

“…1 More recently there have been reports of cocaine users presenting with retiform (net-like or reticulated) purpuric lesions and white blood cell suppression including leukopenia or neutropenia. [2][3][4][5][6] We present 2 additional cases of otherwise unexplained leukopenia and retiform purpuric lesions in patients who tested positive for cocaine.…”