Levamisole-contaminated cocaine: a hairy affair

Abstract

SUMMARYLevamisole-contaminated cocaine can induce severe systemic vasculitis. The diagnosis can be challenging, especially when substance abuse is uncertain. We present the case of a 42-year-old woman suffering from vasculitis due to levamisole-contaminated cocaine, who persistently denied substance abuse. Symptoms included ulcerating skin lesions, arthralgia and myalgia, and the occurrence of an ileal intussusception. The definitive diagnosis was made using hair testing for toxins. She recovered through cocaine abstinence, but re-exposure resulted in a severe relapse with glomerulonephritis. Importantly, at time of the relapse, the patient became positive for both myeloperoxidase-antineutrophil cytoplasmic antibody (ANCA) and proteinase 3-ANCA. Cocaine-levamisole-induced vasculitis poses a great clinical challenge. The proper diagnostic strategy and therapy is still controversial. We highlight our diagnostic and therapeutic considerations, including hair testing for definitive proof of exposure. BACKGROUND

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.…”

Vaskulitis der Haut nach Kokainkonsum

“…Im Rahmen einer ANCA-assoziierten Vaskulitis kann es selten zu einer pauciimmunen, nekrotisierenden Glomerulonephritis kommen [6]. Auch Fälle einer membranösen Nephropathie sind beschrieben worden [7], ebenso wie ein Befall des Darmes [8]. Warum nur bestimmte Konsumenten von mit Levamisol kontaminiertem Kokain betroffen sind, ist unklar.…”

“…Hierzu passt auch, dass bei unserem Patienten der Nachweis von Levamisol im Urin nicht mehr gelingen konnte. Bestehen Zweifel an der Diagnose, kann eine toxikologische Haartestung erwogen werden [8]. Hierdurch kann auch eine zurückliegende Exposition mit Kokain, Levamisol oder anderen Substanzen nachgewiesen werden [12,13].…”

“…Darüber hinaus existiert keine einheitliche Therapieempfehlung. In ausgeprägten Fällen mit ausgebreiteten Läsionen und Organschäden ist eine spezialisierte Schmerzbehandlung sowie immunsupressive Therapie, zum Beispiel mit Cyclophosphamid und/oder hochdosierter Steroidgabe indiziert [8,13].…”

Painful Retiform Purpura with Cutaneous Necrosis

“…6,10 It is important to note, however, that levamisole-induced vasculitis frequently recurs following re-exposure to contaminated cocaine and therefore, complete abstinence must be counseled. 11 The use of levamisole as a cocaine diluent has become increasingly popular, making awareness of levamisole-induced vasculitis imperative for clinicians. To distinguish levamisole-induced vasculitis from other forms of vasculitis, anti-human elastase antibody has been shown to be a useful tool, as it is negative in other types of autoimmune vasculitis.…”