Ear Lobe Bilateral Necrosis by Levamisole‐Induced Occlusive Vasculitis in a Pediatric Patient

Menni, S.; Pistritto, G.; Gianotti, Raffaele; Ghio, Luciana; Edefonti, Alberto

doi:10.1111/j.1525-1470.1997.tb00695.x

Cited by 47 publications

(32 citation statements)

References 7 publications

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“…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 It was withdrawn from the market in 2000 due to its adverse side effect profile, specifically agranulocytosis.…”

Section: Discussionmentioning

confidence: 99%

“…There were no mucosal lesions, lymphadenopathy, or hepatosplenomegaly. Laboratory testing showed a white blood cell (WBC) count of 3200 per mm 3 (normal range of 4500-11,500 per mm 3 ). The platelet count was 148,000 per mm 3 .…”

Section: Case Reportmentioning

confidence: 99%

“…Laboratory testing showed a white blood cell (WBC) count of 3200 per mm 3 (normal range of 4500-11,500 per mm 3 ). The platelet count was 148,000 per mm 3 . Hemoglobin, coagulation studies, urinalysis, basic metabolic panel, renal and hepatic functions were normal.…”

Section: Case Reportmentioning

confidence: 99%

“…1,10 One of the most unique features of this syndrome is that the rash has a predilection for the ears, which has been documented in many case reports and case series. 2,3,8,11,12 It is interesting to speculate on the reason why the ears are preferentially involved. It may be due to the fact that the lower temperature of the ear may facilitate the deposition of immune complexes.…”

mentioning

confidence: 99%

“…20 Similarly, there have been multiple reports of leukopenia and agranulocytosis secondary to the use of cocaine contaminated with levamisole. [21][22][23][24] Gross et al 1 reported that 10 out of 16 patients (63%) with this syndrome had either leukopenia with WBC count less than 4000 per mm 3 or neutropenia with ANC less than 1500 per mm 3 . Of note, leukopenia was present in our patient.…”

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confidence: 99%

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Cutaneous Vasculopathy Associated with Levamisole-Adulterated Cocaine

Tran

Tan

Marnejon

2012

Clinical Medicine & Research

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We report a case of cutaneous vasculopathy associated with the use of levamisole-adulterated cocaine. This recently described clinical entity is characterized by a purpuric rash with a predilection for the ears, leukopenia, and anti-neutrophilic cytoplasmic antibody (ANCA) positivity. It is estimated that more than 70% of the current United States cocaine supply is contaminated with levamisole. Levamisole is a widely available, inexpensive, white powder used as a "cutting agent" in cocaine to expand volume and increase profits. It may also increase the euphoric and stimulatory effects of cocaine by increasing brain dopamine levels and producing amphetamine-like metabolites. Our patient exhibited a characteristic rash with involvement of the ears, leukopenia, and cocaine metabolites were detected in serum and urine. The presence of levamisole was confirmed in the urine utilizing gas chromatography-mass spectrometry. ANCA positivity was also present. Punch biopsy of the skin demonstrated vascular thrombosis and necrosis without true vasculitis. We review the literature for reported cases of cocainelevamisole cutaneous vasculopathy syndrome, highlight the salient immunologic abnormalities, and contrast the features of this entity with idiopathic systemic vasculitis.

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Section: Discussionmentioning

confidence: 99%

Section: Case Reportmentioning

confidence: 99%

Section: Case Reportmentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

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Cutaneous Vasculopathy Associated with Levamisole-Adulterated Cocaine

Tran

Tan

Marnejon

2012

Clinical Medicine & Research

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Purpura, cutaneous necrosis, and antineutrophil cytoplasmic antibodies associated with levamisole-adulterated cocaine

Graf

Lynch

Yeh

et al. 2011

Arthritis & Rheumatism

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Objective. To describe the clinical and serologic abnormalities in 6 patients who presented with retiform purpura and extensive cutaneous necrosis after exposure to levamisole-adulterated cocaine.Methods. All patients were evaluated at San Francisco General Hospital or the University of California San Francisco Medical Center. Each underwent standard screening for substances of abuse and had urine tested for the presence of levamisole by liquid chromatography tandem mass spectrometry. Routine laboratory, autoantibody, and antiphospholipid antibody testing was performed in the hospitals' clinical or reference laboratories. Testing for atypical antineutrophil cytoplasmic antibodies (ANCAs) was performed separately using commercially available enzyme-linked immunosorbent assay kits.Results. The patients were women ages 39-50 years who presented with retiform purpura and cutaneous necrosis. Skin biopsies revealed a predominantly small-vessel thrombotic vasculopathy with varying degrees of vasculitis. Four patients were neutropenic. All tested positive for lupus anticoagulant, had IgM antibodies to cardiolipin, and tested strongly positive for ANCAs in a perinuclear pattern by immunofluorescence. Each patient had antibodies to multiple components of neutrophil granules, including neutrophil elastase, lactoferrin, cathepsin G, proteinase 3, and myeloperoxidase.Conclusion. Rheumatologists should be aware of this distinctive form of necrotic purpura, its associated autoantibodies, and its link to levamisole-adulterated cocaine.

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Drugs, Wound Healing and Cutaneous Ulcers

Wound Healing and Ulcers of the Skin

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Ear Lobe Bilateral Necrosis by Levamisole‐Induced Occlusive Vasculitis in a Pediatric Patient

Cited by 47 publications

References 7 publications

Cutaneous Vasculopathy Associated with Levamisole-Adulterated Cocaine

Cutaneous Vasculopathy Associated with Levamisole-Adulterated Cocaine

Purpura, cutaneous necrosis, and antineutrophil cytoplasmic antibodies associated with levamisole-adulterated cocaine

Drugs, Wound Healing and Cutaneous Ulcers

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