Cocaine and Levamisole Induced Vasculitis

Abstract

Levamisole adulterated cocaine is a rare cause of anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis. It is increasingly diagnosed because of raised awareness; however, it is still underdiagnosed in part because of its rarity and patients not reporting cocaine use. Here we report a case of levamisole-induced vasculitis. We present a 48-year-old non-Hispanic white male with a past medical history significant for Crohn’s Disease and pneumonia who presented with acute bilateral ear pain and rash. His urinary drug screen was positive, which prompted suspicion of contamination and potential levamisole adulterated cocaine-associated vasculitis. A punch biopsy showed evidence of leukocytoclastic vasculitis and multiple fibrin thrombi further supporting contamination with levamisole. We believe this case highlights the importance of using patient history in guiding diagnostic testing in the setting of acute vasculitis. Once the history of illicit substance use was confirmed, our differential diagnosis and considerations for treatment significantly changed.

Molecular Insights and Clinical Outcomes of Drugs of Abuse Adulteration: New Trends and New Psychoactive Substances

“…Suspected substances were levamisole ( n = 10), methaqualone and several benzodiazepines, caffeine and acetaminophen ( n = 1), 5F-MDMB- PINACA ( n = 7) and phenethylamine ( n = 1), asbestos ( n = 1) [ 33 , 42 , 44 , 45 , 46 , 47 , 52 , 53 , 54 , 55 , 56 ]. Considering all of the reported cases, levamisole was the most prevalent adulterating agent in street cocaine ( n = 17 cases) [ 33 , 42 , 44 , 45 , 46 , 47 , 54 , 57 , 58 , 59 , 60 , 61 , 62 ].…”

“…Generally, ANCA positivity is a marker of autoimmune pathologies including systemic autoimmune vasculitis, necrotising crescentic glomerulonephritis, inflammatory bowel disease and other autoimmune pathologies [ 63 ]. In levamisole-adulterated cocaine intoxications [ 33 , 44 , 45 , 46 , 47 , 54 , 57 , 58 , 59 , 60 , 61 , 62 ] the p- or c-ANCA positivity was associated with Cocaine Induced Midline Destructive Lesions (CIMDL) ( n = 5) [ 44 , 57 ], vasculitis ( n = 8) [ 33 , 47 , 58 , 59 , 60 , 61 ], membranous glomerulonephritis ( n = 4) [ 58 , 62 ], pyoderma gangrenosum ( n = 1) [ 54 ], neutropenia complicated with bowel necrosis ( n = 1) [ 46 ], and cerebral white matter dysfunction ( n = 1) [ 45 ]. These autoimmune pathologies were more frequent in women (100% ANCA positivity) than men (90% of ANCA positivity) [ 64 ].…”

Adulteration and substitution of drugs purchased in Australia from cryptomarkets: An analysis of Test4Pay

“…Some of the adulterations and substitutions uncovered by Test4Pay could result in additional harm. These harms relate to (i) unexpected drug effects from totally different drug classes (e.g., someone expecting the psychedelic effects of 2C-B instead consumes novel ketamine analogues, resulting in psychological distress and/or overdose); (ii) problems where similar drugs are substituted (e.g., the synthetic cathinone dimethylpentylone being consumed instead of cocaine, where the drug is more potent and the stimulant effects last much longer) [28]; and (iii) physical health problems in the case of cocaine adulterants like levamisole [29].…”

Drug adulteration and substitution within Australian cryptomarkets: An analysis of Test4Pay

“…Some of the adulterations and substitutions uncovered by Test4Pay could result in additional harm for consumers. These harms relate to: (i) unexpected drug effects from totally different drug classes (e.g., someone expecting the psychedelic effects of 2C-B instead consumes novel ketamine analogues, resulting in psychological distress and/or overdose); (ii) problems where similar drugs are substituted (e.g., the synthetic cathinone dimethylpentylone being consumed instead of cocaine, where the drug is more potent and the stimulant effects last much longer) [19]; (iii) and physical health problems in the case of cocaine adulterants like levamisole [20].…”