title: Syndrome of cocaine-levamisole-induced cutaneous vasculitis and immune-mediated leukopenia.
abstract: OBJECTIVE
  We describe 4 patients who presented with palpable purpura, arthralgia or arthritis, leukopenia, and antineutrophil cytoplasmic antigen (ANCA) positivity most likely as a result of a hypersensitivity reaction to cocaine-levamisole induced vasculopathy.
  
  
  METHODS
  Cases were seen and reviewed in both the inpatient consult service and the outpatient clinics at Rhode Island Hospital from August 2009 to August 2010. Clinical characteristics as well as pertinent laboratory parameters were also reviewed and corroborated with a review of the present literature.
  
  
  RESULTS
  We describe 3 cases of cocaine-levamisole-related cutaneous vasculitis with or without associated neutropenia, and 1 case of severe neutropenia with oral mucosal ulceration. Further serologic studies revealed maximum titers of ANCA mostly in a perinuclear pattern. Antimyeloperoxidase tested negative or mildly elevated in our cohort. Three patients with neutropenia had positive antigranulocyte IgM antibody. Nonsteroidal anti-inflammatory drugs were effective as first-line treatment for joint pain. The use of colchicine and systemic corticosteroid was employed to manage severe and persistent skin lesions.
  
  
  CONCLUSIONS
  Cocaine-levamisole-related cutaneous vasculitis with leukopenia is a diagnosis of exclusion, but this diagnosis should be strongly considered in patients with a history of cocaine abuse who present with a tetrad of cutaneous manifestations consisting of palpable purpura or bullae with ear involvement, arthralgias, leukopenia, and positive ANCA in high titers and negative Antimyeloperoxidase, when other infectious or idiopathic vasculitic entities have been excluded.
authors.affiliation: Division of Rheumatology, Rhode Island Hospital and Warren Alpert School of Medicine at Brown University, Providence, RI 02905, USA.
authors.forename: Samuel H
authors.initials: SH
authors.lastname: Poon
authors.forename: Crisostomo R
authors.initials: CR
authors.lastname: Baliog
authors.forename: Ralph N
authors.initials: RN
authors.lastname: Sams
authors.forename: Leslie
authors.initials: L
authors.lastname: Robinson-Bostom
authors.forename: Gladys H
authors.initials: GH
authors.lastname: Telang
authors.forename: Anthony M
authors.initials: AM
authors.lastname: Reginato
mesh_terms: D018501:Antirheumatic Agents / Q000009:adverse effects*; D003042:Cocaine / Q000009:adverse effects*; D018765:Dopamine Uptake Inhibitors / Q000009:adverse effects*; D005260:Female; D006801:Humans; D007970:Leukopenia / Q000139:chemically induced* / Q000276:immunology / Q000473:pathology; D007978:Levamisole / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D011693:Purpura / Q000139:chemically induced / Q000276:immunology / Q000473:pathology; D018366:Vasculitis, Leukocytoclastic, Cutaneous / Q000139:chemically induced* / Q000276:immunology / Q000473:pathology
chemical_list: D018501:Antirheumatic Agents; D018765:Dopamine Uptake Inhibitors; D007978:Levamisole; D003042:Cocaine