title: Levamisole-induced Wegener's granulomatosis following contaminated cocaine abuse.
abstract: A 44-year-old woman with a medical history of chronic pain syndrome presented with a 3-day history of a painful "rash" that started on her face and spread to her legs. Further history revealed that she recently started a new medication, varenicline, 7 weeks prior to admission and had a long-standing history of intranasal cocaine use. Review of systems was significant for rhinitis, nasal congestion, joint pain, and a febrile episode 2 days prior to admission. Physical examination revealed centrally violaceous, tender, stellate, and retiform purpuric patches and plaques on her extremities, nasal dorsum, and cheeks. Approximately 1.0-centimeter tender purpuric nodules were noted on her bilateral second proximal interphalangeal joints. She was afebrile. Initial laboratory data revealed a mild leukopenia, normal serum urea nitrogen and creatinine without hematuria, and an elevated erythrocyte sedimentation rate. Further analysis showed a normal complement level, negative antinuclear antibody, human immunodeficiency virus, rapid plasma reagin, and hepatitis panel. Trace cryoglobenemia and a positive anti-streptolysin O were noted, along with a positive antineutrophil cytoplasmic antibody (c-ANCA) (> 8.0 U) and perinuclear antineutrophil cytoplasmic antibodies, or p-ANCA (1.5 U). The hypercoagulable workup was negative. A skin biopsy taken from the left thigh was consistent with leukocytoclastic vasculitis. After several weeks of high-dose oral prednisone taper, the patient's symptoms improved, but flared upon discontinuation. On follow-up, she admitted to frequent relapses of cocaine abuse and had developed tender purpuric plaques on her nose, ears, and extremities, some with ulcerations (Figure 1 and Figure 2). She also had significant edema and joint pain that limited her ambulation. Further evaluation revealed normal chest x-ray results; however, computed tomography of her sinuses demonstrated thickened maxillary sinuses consistent with subacute/ chronic sinusitis. She also developed hematuria. Mass spectrometry analysis ofhair and urine samples tested positive for cocaine and levamisole. A presumptive diagnosis of levamisole-induced Wegener's vasculitis was made. She was restarted on high-dose prednisone and methotrexate with improvement and advised to discontinue cocaine use, so as to avoid exposure to both substances.
authors.affiliation: University of Medicine and Dentistry of New Jersey--Robert Wood Johnson Medical School at Camden, NJ, USA. kopp-sandra@cooperhealth.edu
authors.forename: Sandra A
authors.initials: SA
authors.lastname: Kopp
authors.forename: Whitney A
authors.initials: WA
authors.lastname: High
authors.forename: Justin J
authors.initials: JJ
authors.lastname: Green
mesh_terms: D000328:Adult; D000969:Antinematodal Agents / Q000009:adverse effects*; D003042:Cocaine; D019970:Cocaine-Related Disorders / Q000150:complications*; D003879:Dermatologic Agents / Q000008:administration & dosage; D004340:Drug Contamination; D004359:Drug Therapy, Combination; D005260:Female; D005938:Glucocorticoids / Q000008:administration & dosage; D014890:Granulomatosis with Polyangiitis / Q000139:chemically induced* / Q000188:drug therapy; D006801:Humans; D007978:Levamisole / Q000009:adverse effects*; D008727:Methotrexate / Q000008:administration & dosage; D011241:Prednisone / Q000008:administration & dosage
chemical_list: D000969:Antinematodal Agents; D003879:Dermatologic Agents; D005938:Glucocorticoids; D007978:Levamisole; D003042:Cocaine; D011241:Prednisone; D008727:Methotrexate