title: Early excision and grafting, an alternative approach to the surgical management of large body surface area levamisole-adulterated cocaine induced skin necrosis.
abstract: Levamisole-adulterated cocaine as a cause of retiform purpura progressing to full-thickness skin necrosis was first documented in 2003 and currently comprises over 200 reported cases. Whereas, its presentation, pathophysiology, and diagnostic workup have been reasonably well-defined, only one publication has significantly detailed its surgical management. For this reason there exists a relative absence of data in comparison to its reported incidence to suggest a preferred treatment strategy. In the case mentioned, treatment emphasized delayed surgical intervention while awaiting lesion demarcation and the monitoring of autoantibodies. At our institution we offer an alternative approach and present the case of a 34 year old female who presented with 49% TBSA, levamisole-induced skin necrosis managed with early surgical excision and skin grafting. The patient presented three days following cocaine exposure with painful, purpura involving the ears, nose, buttocks, and bilateral lower extremities which quickly progressed to areas of full-thickness necrosis. Lab analysis demonstrated elevated p-ANCA and c-ANCA, as well as leukopenia, decreased C4 complement, and urinalysis positive for levamisole, corroborating the diagnosis. Contrasting the most thoroughly documented case in which the patient underwent first surgical excision on hospital day 36 and underwent 18 total excisions, our patient underwent first excision on hospital day 10 and received only one primary excision prior to definitive autografting. To our knowledge, this is the largest surface area surgically treated that did not result in surgical amputation or autoamputation of limbs or appendages, respectively. We contend that early excision and grafting provides optimal surgical management of this syndrome while avoiding the morbidity seen with delayed intervention.
authors.affiliation: Wright State University Department of Surgery, Division of Burns and Wounds at Miami Valley Hospital Regional Burn and Wound Center, One Wyoming St., Dayton, OH 45409, United States; Unites States Air Force, United States.
authors.forename: Jason
authors.initials: J
authors.lastname: Miner
authors.affiliation: Wright State University Department of Surgery, Division of Burns and Wounds at Miami Valley Hospital Regional Burn and Wound Center, One Wyoming St., Dayton, OH 45409, United States.
authors.forename: Paul
authors.initials: P
authors.lastname: Gruber
authors.affiliation: Wright State University Department of Surgery, Division of Burns and Wounds at Miami Valley Hospital Regional Burn and Wound Center, One Wyoming St., Dayton, OH 45409, United States. Electronic address: tlperry@mvh.org.
authors.forename: Travis L
authors.initials: TL
authors.lastname: Perry
mesh_terms: D000276:Adjuvants, Immunologic / Q000009:adverse effects*; D000328:Adult; D056648:Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis / Q000139:chemically induced / Q000276:immunology / Q000601:surgery*; D001830:Body Surface Area; D003042:Cocaine; D019970:Cocaine-Related Disorders; D003646:Debridement / Q000379:methods; D004340:Drug Contamination; D061345:Early Medical Intervention; D005260:Female; D006801:Humans; D007978:Levamisole / Q000009:adverse effects*; D009336:Necrosis / Q000601:surgery; D012867:Skin / Q000473:pathology*; D017445:Skin Diseases, Vascular / Q000139:chemically induced / Q000276:immunology / Q000601:surgery*; D016038:Skin Transplantation / Q000379:methods*
chemical_list: D000276:Adjuvants, Immunologic; D007978:Levamisole; D003042:Cocaine
keywords: Autoimmune vasculitis; Cocaine; Debridement; Early excision and grafting; Full-thickness; Levamisole; Skin graft; Skin necrosis; Surgical management