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LEVAMISOLE INDUCED VASCULITIS IN A COCAINE USER
Joseph Blatt MD
Medical University of South Carolina, Charleston, South Carolina
LEVAMISOLE
LEARNING OBJECTIVES
An imidizothiazole previously used for
antihelmin and immunomodulatory
effects
1. Recognize levamisole is an increasingly
common cocaine adulterant with serious
health consequences.
Withdrawn from US market in 2000 for
side effects of vasculitis and
agranulocytosis
2. Suspect exposure to levamisole in
patients presenting with unexplained
neutropenia, necrotic skin lesions, and a
history of cocaine use.
In 2000 became recognized as a
cocaine adulterant – undetectable on
street market and may enhance
euphoric effects of cocaine
CASE PRESENTATION
CDC reports 70% of US supply of
cocaine my be adulterated with
levamisole
40 yo WF with admitted for rash
beginning on the legs with
progression to the ears, abdomen,
chest, bilateral elbows, scalp
PE: retiform purpura in various stages
of abscess formation and central
necrosis
CONCLUSIONS
Figure 1. Retiform purpura of Levamisole Vasculitis .
LEVAMISOLE INDUCED VASCULOPATHY
PMH: frequent cocaine use, Hep C
LABS: UDS cocaine+, pANCA>1:1280, MPO positive, RF 24,
urine levamisole
BIOPSY: Leukocytoclastic vasculitis
with thrombotic vasculopathy
HOSPITAL COURSE :
Patient counseled on importance of
cessation of cocaine use
IV steroids for positive p-ANCA
Vancomycin for superimposed
MRSA infection
Painful retiform purpura with
evolution to necrosis
Agranulocytosis, neutropenia
Autoantibodies: MPO, p-ANCA>cANCA, human neutrophil elastase,
ACL, PR3
Urine levamisole: half-life 5.6 hours
Cocaine use
Purpura typically present on nose
and ears
Primary treatment is cessation of
cocaine
Ulcers may require debridement,
Monitor for superinfection
1. With >2 million Americans using
cocaine, occurrences of levamisole
induced vasculitis will increase.
2. Levamisole exposure should be
included in the differential of
patients with purpuric vasculitis,
neutropenia, and cocaine use.
REFERENCES
1.
Centers for Disease Control and Prevention (CDC). Agranulocytosis associated with
cocaine use – four states, March 2008-November 2009. MMWR Morb Mortal Wkly Rep
2009:58;1381-1385.
2.
Buchanan JA. A confirmed case of agranulocytosis after use of cocaine contaminated with
levamisole. J Med Toxicol 2010:6;160-164.
3.
Lauren Geller MD1. Retiform purpura: A new stigmata of illicit drug use?
Dermatology Online Journal 17 (2): 7.
4.
Tahir A. KhanMD. Vasculopathy, Hematological, and Immune Abnormalities Associated
with Levamisole-Contaminated Cocaine Use.Semin Arthritits Rheum 2011: 41:445-454.
5.
Waller JM. Cocaine-associated retiform purpura and neutropenia: Is levamisole the
culprit? J Am Acad Dermatol 2010;63:530-535.
Special Thanks: Vivianne Beyer MD, Cynthia Wilson MD, Ross Pollack MD, Julie Swick MD,
Paul Anderson MD, Keri Holmes-Maybank MD