Cutaneous vasculopathy associated with levamisole-adulterated cocaine.
We report a case of cutaneous vasculopathy associated with the use of levamisole-adulterated cocaine. This recently described clinical entity is characterized by a purpuric rash with a predilection for the ears, leukopenia, and anti-neutrophilic cytoplasmic antibody (ANCA) positivity. It is estimated that more than 70% of the current United States cocaine supply is contaminated with levamisole. Levamisole is a widely available, inexpensive, white powder used as a "cutting agent" in cocaine to expand volume and increase profits. It may also increase the euphoric and stimulatory effects of cocaine by increasing brain dopamine levels and producing amphetamine-like metabolites. Our patient exhibited a characteristic rash with involvement of the ears, leukopenia, and cocaine metabolites were detected in serum and urine. The presence of levamisole was confirmed in the urine utilizing gas chromatography-mass spectrometry. ANCA positivity was also present. Punch biopsy of the skin demonstrated vascular thrombosis and necrosis without true vasculitis. We review the literature for reported cases of cocaine-levamisole cutaneous vasculopathy syndrome, highlight the salient immunologic abnormalities, and contrast the features of this entity with idiopathic systemic vasculitis.
Internal Medicine Residency Program, Department of Medicine, St. Elizabeth Health Center, Youngstown, OH 44501, USA.
Huy
H
Tran
Debbie
D
Tan
Thomas P
TP
Marnejon
D019268:Antibodies, Antineutrophil Cytoplasmic / Q000097:blood; D001706:Biopsy; D003042:Cocaine / Q000009:adverse effects*; D004340:Drug Contamination; D005076:Exanthema / Q000473:pathology; D006801:Humans; D007970:Leukopenia / Q000097:blood; D007978:Levamisole / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D012867:Skin / Q000473:pathology; D017445:Skin Diseases, Vascular / Q000139:chemically induced* / Q000175:diagnosis* / Q000473:pathology; D013577:Syndrome
D019268:Antibodies, Antineutrophil Cytoplasmic; D007978:Levamisole; D003042:Cocaine