title: Cutaneous vasculopathy and neutropenia associated with levamisole-adulterated cocaine.
abstract: BACKGROUND
  Levamisole has recently been implicated as a cause of cutaneous vasculopathy in cocaine abusers. The objective of this study was to describe this relatively new entity by reviewing published cases identified through a literature search.
  
  
  METHODS
  Published reports identified through a search of PubMed database (from 1964 to November 2011) were reviewed to record clinical, serological and pathologic findings.
  
  
  RESULTS
  A cohort of 32 patients had a mean age of 44 ± 9 years with a female predominance (75%). Rash predominately affected lower extremities (87.5%), followed by face (78%) and ears (69%) and typically presented as purpuric plaques, which were seen in a retiform pattern in 16 (50%) and had central necrosis in 11 patients (34%). Leukopenia and neutropenia were found in 20 patients (63%). Antinuclear cytoplasmic antibody (ANCA) was positive in 30 patients (94%); p-ANCA in 28 patients (87.5%), c-ANCA in 19 (59%) and both in 17 patients (53%). Skin biopsy results were available for 29 patients: 14 (48%) had pure thrombotic vasculopathy, 4 (14%) had pure small vessel vasculitis and 11 (38%) had evidence of both. Treatment information was available for 30 patients. Only supportive care was given to 11 patients (37%), steroids to 16 (53%) and surgical treatment for 5 (17%). Clinical course of lesions was available for 24 patients. Rash resolved in 11 patients (46%) and improved in 13 (54%). During median follow-up of 21 days (range, 7-270 days), 10 of 22 patients had recurrences related to cocaine use.
  
  
  CONCLUSIONS
  Levamisole-induced cutaneous vasculopathy in cocaine users is characterized by a female predominance, a retiform purpuric rash with a predilection for lower extremities, autoantibody production, leukopenia and/or neutropenia and recurrences with future cocaine use.
authors.affiliation: Department of Internal Medicine, Wayne State University School of Medicine, Detroit Medical Center, Detroit, MI, USA. narora@med.wayne.edu
authors.forename: Natasha Purai
authors.initials: NP
authors.lastname: Arora
mesh_terms: D000328:Adult; D000969:Antinematodal Agents / Q000009:adverse effects*; D003042:Cocaine / Q000009:adverse effects; D005260:Female; D006801:Humans; D007978:Levamisole / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D009503:Neutropenia / Q000139:chemically induced*; D012867:Skin / Q000473:pathology; D017445:Skin Diseases, Vascular / Q000097:blood / Q000139:chemically induced* / Q000473:pathology; D014662:Vasoconstrictor Agents / Q000009:adverse effects
chemical_list: D000969:Antinematodal Agents; D014662:Vasoconstrictor Agents; D007978:Levamisole; D003042:Cocaine