Levamisole-induced leukocytoclastic vasculitis and neutropenia in a patient with cocaine use: An extensive case with necrosis of skin, soft tissue, and cartilage
Tóm tắt
Levamisole-induced vasculitis is a relatively new entity in people who use cocaine. We describe a 44-year-old woman with a history of cocaine use who presented with a complaint of a painful rash of 2-3 month’s duration on her extremities, cheeks, nose, and earlobes. She had not experienced fever, weight loss, alopecia, dry eyes, oral ulcers, photosensitivity, or arthralgia. Examination revealed tender purpuric eruptions with central necrosis on her nose, cheeks, earlobes, and extremities. Laboratory investigations revealed neutropenia, an elevated erythrocyte sedimentation rate (ESR), presence of lupus anticoagulant, low complement component 3 (C3), and presence of perinuclear anti-neutrophil cytoplasmic antibody (p-ANCA). A urine toxicology screen was positive for cocaine, and gas chromatography–mass spectrometry was positive for levamisole. Skin biopsy showed leukocytoclastic vasculitis and small vessel thrombosis. Necrotic lesions of the nose led to its self-amputation. Large bullae on the lower extremities ruptured, leading to wound infection and extensive necrosis that required multiple surgical debridements. When necrosis progressed despite debridement, bilateral above-knee amputation of the legs was performed. Once new lesions stopped appearing, the patient was discharged home. Two months later, she had a recurrence related to cocaine use. To the best of our knowledge, this is only the second reported case of levamisole-induced vasculitis that required above-knee amputation.
Tài liệu tham khảo
Buchanan JA, Heard K, Burbach C, Wilson ML, Dart R: Prevalence of levamisole in urine toxicology screens positive for cocaine in an inner-city hospital. JAMA. 2011, 305 (16): 1657-1658. 10.1001/jama.2011.531.
Centers for Disease Control and Prevention (CDC): Agranulocytosis associated with cocaine use—four States, March 2008-November 2009. MMWR Morb Mortal Wkly Rep. 2009, 58: 1381-1385.
Gross RL, Brucker J, Bahce-Altuntas A, Abadi MA, Lipoff J, Kotlyar D, Barland P, Putterman C: A novel cutaneous vasculitis syndrome induced by levamisole-contaminated cocaine. Clin Rheumatol. 2011, 30 (10): 1385-1392. 10.1007/s10067-011-1805-3.
Ullrich K, Koval R, Koval E, Bapoje S, Hirsh JM: Five consecutive cases of a cutaneous vasculopathy in users of levamisole-adulterated cocaine. J Clin Rheumatol. 2011, 17 (4): 193-196.
Amery WK, Bruynseels JP: Levamisole, the story and the lessons. Int J Immunopharmacol. 1992, 14 (3): 481-486. 10.1016/0192-0561(92)90179-O.
Macfarlane DG, Bacon PA: Levamisole-induced vasculitis due to circulating immune complexes. Br Med J. 1978, 1 (6110): 407-408. 10.1136/bmj.1.6110.407.
Bradford M, Rosenberg B, Moreno J, Dumyati G: Bilateral necrosis of earlobes and cheeks: another complication of cocaine contaminated with levamisole. Ann Intern Med. 2010, 152 (11): 758-759.
Buchanan JA, Vogel JA, Eberhardt AM: Levamisole-induced occlusive necrotizing vasculitis of the ears after use of cocaine contaminated with levamisole. J Med Toxicol. 2011, 7 (1): 83-84. 10.1007/s13181-010-0097-3.
Walsh NMG, Green PJ, Burlingame RW, Pasternak S, Hanly JG: Cocaine-related retiform purpura: evidence to incriminate the adulterant, levamisole. J Cutan Pathol. 2010, 37 (12): 1212-1219. 10.1111/j.1600-0560.2010.01613.x.
Waller JM, Feramisco JD, Alberta-Wszolek L, McCalmont TH, Fox LP: Cocaine-associated retiform purpura and neutropenia: is levamisole the culprit?. J Am Acad Dermatol. 2010, 63 (3): 530-535. 10.1016/j.jaad.2010.01.055.
Farhat EK, Moorhead TT, Chaffing ML, Douglass MC: Levamisole-induced cutaneous necrosis mimicking coagulopathy. Arch Dermatol. 2010, 146 (11): 1320-1321. 10.1001/archdermatol.2010.335.
Click J: Levamisole-induced retiform purpura. J Drug Dermatol. 2011, 10 (2): 217-
Geller L, Whang TB, Mercer SE, Phelps R: Retiform purpura: a new stigmata of illicit drug use?. Dermatol Online J. 2011, 17 (2): 7.
Han C, Sreenivasan G, Dutz JP: Reversible retiform purpura: a sign of cocaine use. CMAJ. 2011, 183 (9): 597-600. 10.1503/cmaj.101005.
Ching JA, Smith DJ: Levamisole-induced necrosis of skin, soft tissue, and bone: case report and review of literature. J Burn Care Res. 2012, 33 (1): 1-5. 10.1097/BCR.0b013e31823347f6.
Mouzakis J, Somboonwit C, Lakshmi S, Rumbak M, Sinnott J, Cherpelis B, Keshishian J: Levamisole-induced necrosis of the skin and neutropenia following intranasal cocaine use: a newly recognized syndrome. J Drugs Dermatol. 2011, 10 (10): 1204-1207.
Jacob RS, Silva CY, Powers JG, Schieke SM, Mendese G, Burlingame RW, Miller DD, Wolpowitz D, Graber E, Mahalingam M: Levamisole-induced vasculopathy: a report of 2 cases and a novel histopathologic finding. Am J Dermatopathol. 2012, 34 (2): 208-213. 10.1097/DAD.0b013e31821cc0bf.
Lung D, Lynch K, Agrawal S, Armenian P, Banh K: Images in emergency medicine, adult female with rash on lower extremities. vasculopathic purpura and neutropenia caused by levamisole-contaminated cocaine. Ann Emerg Med. 2011, 57 (3): 307-311. 10.1016/j.annemergmed.2010.05.009.
Zwang NA, Van Wagner LB, Rose S: A case of levamisole-induced systemic vasculitis and cocaine-induced midline destructive lesion: a case report. J Clin Rheumatol. 2011, 17 (4): 197-200.
Chung C, Tumeh PC, Birnbaum R, Tan BH, Sharp L, McCoy E, Mercurio MG, Craft N: Characteristic purpura of the ears, vasculitis, and neutropenia–a potential public health epidemic associated with levamisole-adulterated cocaine. J Am Acad Dermatol. 2011, 65 (4): 722-725. 10.1016/j.jaad.2010.08.024.
Jenkins J, Babu K, Hsu-Hung E, Robinson-Bostom L, Kroumpouzos G: ANCA-positive necrotizing vasculitis and thrombotic vasculopathy induced by levamisole-adulterated cocaine: a distinctive clinicopathologic presentation. J Am Acad Dermatol. 2011, 65 (1): 14-16.
John S, Manda S, Hamrock D: Cocaine-induced thrombotic vasculopathy. Am J Med Sci. 2011, 342 (6): 524-526. 10.1097/MAJ.0b013e31822979f1.
Parkinson DR, Cano PO, Jerry LM, Capek A, Shibata HR, Mansell PW, Lewis MG, Marquis G: Complications of cancer immunotherapy with levamisole. Lancet. 1977, 1 (8022): 1129-1132.
Segal AW, Pugh SF, Levi AJ, Loewi G: Levamisole-induced arthritis in Crohn’s disease. Br Med J. 1977, 2 (6086): 555.
Laux-End R, Inabenit D, Gerber HA, Bianchetti MG: Vasculitis associated with levamisole and circulating autoantibodies. Arch Dis Child. 1996, 75 (4): 355-356.
Chang A, Osterloh J, Thomas J: Levamisole: a dangerous new adulterant. Clin Pharmacol Ther. 2010, 88 (3): 408-411. 10.1038/clpt.2010.156.
McKellar Q, Marriner S, Bogan J: Comparison of ivermectin, oxfendazole and levamisole for use as anthelmintics during the periparturient period in sheep. Vet Rec. 1988, 122 (23): 558-560. 10.1136/vr.122.23.558.
Hembry FG, Miller JE, Sims D, Rodriguez S, Stagg LC: Efficacy of repeated doses of levamisole, morantel, fenbendazole, and ivermectin against gastrointestinal nematodes in ewes. Am J Vet Res. 1986, 47 (8): 1677-1679.
Casale JF, Corbeil EM, Hays PA: Identification of levamisole impurities found in illicit cocaine exhibits. Microgram J. 2008, 6 (3,4): 82-89.
Rothman RB, Baumann MH, Dersch CM, Romero DV, Rice KC, Carroll FI, Partilla JS: Amphetamine-type central nervous system stimulants release norepinephrine more potently than they release dopamine and serotonin. Synapse. 2001, 39 (1): 32-41. 10.1002/1098-2396(20010101)39:1<32::AID-SYN5>3.0.CO;2-3.
Howell LL, Kimmel HL: Monoamine transporters and psychostimulant addiction. Biochem Pharmacol. 2008, 75 (1): 196-217. 10.1016/j.bcp.2007.08.003.
Martin RJ: Modes of action of anthelmintic drugs. Vet J. 1997, 154 (1): 11-34. 10.1016/S1090-0233(05)80005-X.
Raymon LP, Isenschmid DS: Letter to the editor: the possible role of levamisole in illicit cocaine preparations. J Anal Toxicol. 2009, 33 (9): 620-622.
Ho EN, Leung DK, Leung GN, Wan TS, Wong AS, Wong CH, Soma LR, Rudy JA, Uboh C, Sams R: Aminorex and rexamino as metabolites of levamisole in the horse. Anal Chim Acta. 2009, 638 (1): 58-68. 10.1016/j.aca.2009.02.033.
Shannon M: Clinical toxicity of cocaine adulterants. Ann Emerg Med. 1988, 17 (11): 1243-1247. 10.1016/S0196-0644(88)80078-7.
Friedman DR, Wolfsthal SD: Cocaine-induced pseudovasculitis. Mayo Clin Proc. 2005, 80 (5): 671-673. 10.4065/80.5.671.
Office of Applied Studies (OAS), Substance Abuse and Mental Health Services Administration (SAMHSA): The. 2005,http://www.oas.samhsa.gov/2k5/cocaine/cocaine.pdf, National Survey on Drug Use and Health Report,