Retiform Purpura of the Lower Limbs Associated with Levamisole-Adulterated Cocaine

Abstract

A young man was treated in hospital for sepsis, disseminated intravascular coagulation and multi-organ failure. He was a regular intranasal cocaine user up to 1 day prior to symptom onset. Clinical examination revealed extensive retiform purpura affecting both his lower limbs. Skin biopsy revealed widespread thrombosis in the small- and medium-sized vessels of the mid dermis and the subcutaneous fat with surrounding leucocytoclasis. There was also extensive ischaemic necrosis of the upper reticular and papillary dermis and focal ischaemic necrosis of the epidermis. These findings were in keeping with a thrombotic vasculopathy with associated cutaneous ischaemic necrosis, likely associated with levamisole-adulterated cocaine (LAC). An autoimmune screen showed extremely raised levels of anti-B2-glycoprotein IgM, IgG and anti-cardiolipin IgG antibodies, usually seen in antiphospholipid syndrome (APS). The literature describes how APS could be secondary to various underlying conditions, including LAC, and that levamisole toxicity may mimic APS and hence be missed.

Retiform Ulceration and Bullae on the Bilateral Thighs

“…Levamisole is currently used as a veterinary antiparasitic, formerly used as an immunomodulatory agent in humans, and popularly added to cocaine due to its psychotropic-enhancing effects . Levamisole-associated cutaneous vasculitis is believed to occur from a combination of immune cascade activation and vasoconstriction . It presents with painful purpuric retiform plaques with central necrosis, most commonly on the distal extremities, ear helices, and nose.…”

“…It presents with painful purpuric retiform plaques with central necrosis, most commonly on the distal extremities, ear helices, and nose. Systemic findings include leukopenia, agranulocytosis, glomerulonephritis, and elevated antineutrophilic cytoplasmic antibodies . Leukocytoclastic vasculitis and thrombotic vasculopathy may be seen histologically.…”

“…4 Levamisole-associated cutaneous vasculitis is believed to occur from a combination of immune cascade activation and vasoconstriction. 4,5 It presents with painful purpuric retiform plaques with central necrosis, most commonly on the distal extremities, ear helices, and nose. Systemic findings include leukopenia, agranulocytosis, glomerulonephritis, and elevated antineutrophilic cytoplasmic antibodies.…”

“…Systemic findings include leukopenia, agranulocytosis, glomerulonephritis, and elevated antineutrophilic cytoplasmic antibodies. 5,6 Leukocytoclastic vasculitis and thrombotic vasculopathy may be seen histologically. Vasculopathy suggests thromboem-bolism and warrants a broad hypercoagulability workup, while vessel wall destruction may be secondary to depositional disorders, infection, or vasculitides.…”