Levamisole-induced leukocytoclastic vasculitis and neutropenia in a patient with cocaine use: An extensive case with necrosis of skin, soft tissue, and cartilage

Abstract

Levamisole-induced vasculitis is a relatively new entity in people who use cocaine. We describe a 44-year-old woman with a history of cocaine use who presented with a complaint of a painful rash of 2-3 month’s duration on her extremities, cheeks, nose, and earlobes. She had not experienced fever, weight loss, alopecia, dry eyes, oral ulcers, photosensitivity, or arthralgia. Examination revealed tender purpuric eruptions with central necrosis on her nose, cheeks, earlobes, and extremities. Laboratory investigations revealed neutropenia, an elevated erythrocyte sedimentation rate (ESR), presence of lupus anticoagulant, low complement component 3 (C3), and presence of perinuclear anti-neutrophil cytoplasmic antibody (p-ANCA). A urine toxicology screen was positive for cocaine, and gas chromatography–mass spectrometry was positive for levamisole. Skin biopsy showed leukocytoclastic vasculitis and small vessel thrombosis. Necrotic lesions of the nose led to its self-amputation. Large bullae on the lower extremities ruptured, leading to wound infection and extensive necrosis that required multiple surgical debridements. When necrosis progressed despite debridement, bilateral above-knee amputation of the legs was performed. Once new lesions stopped appearing, the patient was discharged home. Two months later, she had a recurrence related to cocaine use. To the best of our knowledge, this is only the second reported case of levamisole-induced vasculitis that required above-knee amputation.

Levamisole-Induced Vasculitis: A Characteristic Cutaneous Vasculitis Associated With Levamisole-Adulterated Cocaine

“…7,16 Bulla formation is not uncommon and, with subsequent skin sloughing, bacterial superinfection can increase morbidity. 12 Lesions of the ear and digits have been reported to self-amputate. 12 In addition to the cutaneous manifestations, laboratory findings include leukopenia, neutropenia (including agranulocytosis), elevated erythrocyte sedimentation rate, normal coagulation studies, and positive autoantibodies including perinuclear and cytoplasmic ANCAs (p-and c-ANCAs), antinuclear antibody, and lupus anticoagulant.…”

“…12 Patients typically present with a tender, purpuric rash in a retiform or stellate pattern with or without central necrosis involving the extremities, trunk, nasal tip, digits, cheeks, and/or ears ( Figure 1). 7,16 Bulla formation is not uncommon and, with subsequent skin sloughing, bacterial superinfection can increase morbidity.…”

“…[5][6][7][8][9][10] Soon after, researchers isolated levamisole using urine toxicology and gas chromatographymass spectrometry studies in patients with suspected levamisole-induced vasculitis, confirming prior suspicions that it was in fact the etiologic agent. 11,12 Approximately 70% of the cocaine in the United States contains levamisole, which is used to add volume and weight to the drug and possibly to potentiate the psychotropic effects of cocaine. 3,13,14 Levamisole has been detected in cocaine since 2003, and detection has only increased in recent years.…”

Vanishing vasculitis: a case of acute necrotic skin findings without pathologic features of vasculitis from adulterated cocaine

“…Moreover, levamisole itself can act as the hapten and thus can potentiate the formation of antibodies to antigens resulting in an immune response that can cause leukocyte destruction [9]. Recent findings are also pointing towards the release of inflammatory NETS (neutrophil extracellular traps) in the pathogenesis of cellular and tissue injury [10].…”

Kokainle İlişkili Lökositoklastik Vaskülit

“…Psödovaskülit sonucu gelişen orofarengeal ülserler Wegener granülomatozu ile karıştırılabilir (9). Literatürde bildirilen bir olguda eksüdalı ülsere deri lezyonlarına ilave olarak orofarinksde kalın-gri membran görülmüş ve hastanın wegener granülomatozu olduğu düşünülmüştür.…”