title: Contaminated cocaine and antineutrophil cytoplasmic antibody-associated disease.
abstract: OBJECTIVE
  Approximately 70% of illicit cocaine consumed in the United States is contaminated with levamisole. Most commonly used as a veterinary antihelminthic agent, levamisole is a known immunomodulating agent. Prolonged use in humans has been associated with cutaneous vasculitis and agranulocytosis. We describe the development of a systemic autoimmune disease associated with antineutrophil cytoplasmic antibodies (ANCA) in cocaine users. This complication appears to be linked to combined cocaine and levamisole exposure.
  
  
  METHODS
  Cases were identified between March 2009 and November 2010 at Massachusetts General Hospital's ANCA laboratory. Cocaine exposure was identified from patient history in all cases. Medical records were reviewed for clinical presentation and for laboratory and diagnostic evaluation.
  
  
  RESULTS
  Thirty cases of ANCA positivity associated with cocaine ingestion were identified. All had antimyeloperoxidase antibodies and 50% also had antiproteinase 3 antibodies. Complete clinical and laboratory data were available for 18 patients. Arthralgia (83%) and skin lesions (61%) were the most frequent complaints at presentation. Seventy-two percent of patients reported constitutional symptoms, including fever, night sweats, weight loss, or malaise. Four patients had biopsy-proven vasculitis. Two cases of acute kidney injury and three cases of pulmonary hemorrhage occurred. From the entire cohort of 30, two cases were identified during the first 3 months of our study period and nine cases presented during the last 3 months.
  
  
  CONCLUSIONS
  We describe an association between the ingestion of levamisole-contaminated cocaine and ANCA-associated systemic autoimmune disease. Our data suggest that this is a potentially life-threatening complication of cocaine use.
authors: Renal Division, Brigham and Women’s Hospital, Boston, Massachusetts, USA.
authors: Martina M
authors: MM
authors: McGrath
authors: Tamara
authors: T
authors: Isakova
authors: Helmut G
authors: HG
authors: Rennke
authors: Ann M
authors: AM
authors: Mottola
authors: Karen A
authors: KA
authors: Laliberte
authors: John L
authors: JL
authors: Niles
mesh_terms: D000276:Adjuvants, Immunologic / Q000009:adverse effects*; D000328:Adult; D019268:Antibodies, Antineutrophil Cytoplasmic / Q000032:analysis*; D001327:Autoimmune Diseases / Q000139:chemically induced*; D019970:Cocaine-Related Disorders / Q000150:complications*; D003404:Creatinine / Q000097:blood; D004340:Drug Contamination; D005260:Female; D006801:Humans; D007978:Levamisole / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D053146:Myeloblastin / Q000276:immunology; D009195:Peroxidase / Q000276:immunology
chemical_list: D000276:Adjuvants, Immunologic; D019268:Antibodies, Antineutrophil Cytoplasmic; D007978:Levamisole; D003404:Creatinine; D009195:Peroxidase; D053146:Myeloblastin