Cocaine-associated retiform purpura and neutropenia: Is levamisole the culprit?

Waller, Joseph; Feramisco, Jamison D.; Alberta‐Wszolek, Lauren; McCalmont, Timothy H.; Fox, Lindy P.

doi:10.1016/j.jaad.2010.01.055

Cited by 87 publications

(87 citation statements)

References 6 publications

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“…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.…”

Section: Discussionmentioning

confidence: 99%

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Levamisole-Adulterated Cocaine: A Case Series

Morris

Mason²,

Sprunger³

et al. 2012

The Journal of the American Board of Family Medicine

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The percentage of cocaine adulterated with levamisole is steadily increasing in the United States. In susceptible persons, this combination of drugs leads to a clinical syndrome that can include leukopenia and cutaneous manifestations. Many patients also demonstrate positive autoimmune markers. Biopsies of skin lesions often reveal a thrombotic pattern, leukocytoclastic vasculitis, or both. We report 2 cases of this clinical phenomenon, one of which was severe enough to require skin grafting. It is important for clinicians be aware of this emerging public health threat. (J Am Board Fam Med 2012;25:531-535.)

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Section: Discussionmentioning

confidence: 99%

“…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.…”

mentioning

confidence: 99%

Levamisole-Adulterated Cocaine: A Case Series

Morris

Mason²,

Sprunger³

et al. 2012

The Journal of the American Board of Family Medicine

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“…Current reports of levamisole toxicity describe adults presenting with purpura preferentially involving the ears, neutropenia, positive ANCA, and positive antiphospholipid antibodies. [10][11][12] Since 2002, there have been at least 20 confirmed cases of agranulocytosis and two deaths associated with levamisole-adulterated cocaine. 8,13,14 In September 2009, the Department of Health and Human Services issued a public health alert warning of an impending increase in levamisole-related illness.…”

Section: Discussionmentioning

confidence: 99%

Cracking the case

Kneeland

Dhaliwal

2011

Journal of Hospital Medicine

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The approach to clinical conundrums by an expert clinician is revealed through presentation of an actual patient's case in an approach typical of morning report. Similar to patient care, sequential pieces of information are provided to the clinician who is unfamiliar with the case. The focus is on the thought processes of both the clinical team caring for the patient and the discussant. A 43-year-old woman presented to an outside hospital with painful plaques and patches on her bilateral lower extremities. Two weeks prior to presentation, she had noticed a single red lesion on her left ankle. Over the next two weeks, the lesion enlarged to involve the lower half of her posterior calf and subsequently turned purple and became exquisitely tender. Similar but smaller purple, tender lesions simultaneously appeared, first over her right shin and then on her bilateral thighs and hips. She also reported fatigue as well as diffuse joint pains in her hands and wrists bilaterally for the past month. She denied any swelling of these joints or functional impairment. She denied fevers, weight loss, headache, sinus symptoms, difficulty breathing, or abdominal pain.Although we do not yet have a physical exam, the tempo, pattern of spread, and accompanying features allow some early hypotheses to be considered. Distal lower extremity lesions which darkened and spread could be erythema nodosum or erythema induratum. Malignancies rarely have such prominent skin manifestations, although leukemia cutis or an aggressive cutaneous T cell lymphoma might present with disseminated and darkened plaques, and Kaposi's sarcoma is characteristically purple and multifocal. Autoimmune disorders such as sarcoidosis, cutaneous lupus, and psoriasis may similarly present with widespread plaques. Most disseminated infections that start with patches evolve to pustules, ulcers, bullae, or other forms that reflect the invasive nature of the infection; syphilis warrants consideration for any widespread eruption of unknown etiology. Antecedent arthralgias with fatigue suggest an autoimmune condition, although infections such as hepatitis or parvovirus can do the same. Systemic lupus erythematosus (SLE) or rheumatoid arthritis (RA) would be favored initially on account of her demographics and the hand and wrist involvement, and each can be associated with vasculitis. The significant pain as described is not compatible with most of the aforementioned diagnoses. Its presence, coupled with potential autoimmune symptoms, suggests a vasculitis such as polyarteritis nodosa (which can have prominent diffuse skin involvement), Henoch Schonlein purpura (with its predilection for the lower extremities, including extension to the hips and buttocks), cryoglobulinemia, or SLE-or RA-associated vasculitis. Calciphylaxis is another ischemic vascular disorder that can cause diffuse dark painful lesions, but this only warrants consideration if advanced renal disease is present.A skin biopsy of her right hip was taken at the outside hospital. She was discharged on a two-wee...

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“…Patients present clinically with retiform purpura and skin biopsy shows a leukocytoclastic vasculitis with thrombosis (Walsh et al, 2010). Mural fibrin, extravasated red blood cells, nuclear dust, and luminal thrombosis can also be seen (see Figure 7) (Waller et al, 2010). A diagnostic pit fall for clinicians and dermatopathologists is "cocaine-induced pseudovasculitis" in which the clinical and serologic findings are suggestive of vasculitis, but the histopathologic findings of vasculitis are absent (Friedman & Wolfsthal, 2005).…”

Section: Drug Induced Vasculitismentioning

confidence: 99%

“…A diagnostic pit fall for clinicians and dermatopathologists is "cocaine-induced pseudovasculitis" in which the clinical and serologic findings are suggestive of vasculitis, but the histopathologic findings of vasculitis are absent (Friedman & Wolfsthal, 2005). These patients can also present with retiform purpura and skin biopsy shows fibrin thrombi occluding small superficial and deep dermal vessels without evidence of vasculitis (Waller et al, 2010). …”

Section: Drug Induced Vasculitismentioning

confidence: 99%