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Levamisole-induced vasculitis with ecchymosis and necrosis syndrome from contaminated cocaine
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  1. Nayan Desai1,
  2. Monaliben Patel1,
  3. Shivang Desai2,
  4. Elizabeth Cerceo1
  1. 1Department of Medicine, Cooper University Hospital, Camden, New Jersey, USA
  2. 2Department of Radiodiagnosis, Padmashree Dr D Y Patil Univeristy, Mumbai, Maharashtra, India
  1. Correspondence to Dr Nayan Desai, nayandesai_16{at}yahoo.co.in

https://doi.org/10.1136/bcr-2012-007319

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    Description

    A 43-year-old-man presented with 1-month history of progressive erythematous painful lesions over multiple sites involving bilateral lower extremities, trunk and pinnae. He was a chronic cocaine user; last use was 3 days prior to presentation. On examination he had bilateral large retiform, geometric, dusky, erythematous, tender plaques with central necrosis and ecchymosis over aforementioned areas (figures 1 and 2). There was significant necrosis of helical rims of pinnae. (figure 3). He had leucopenia with neutropenia on complete blood count. Perinuclear-antineutrophil cytoplasmic antibody (p-ANCA) was positive. Urine drug screen was positive for cocaine and levamisole was detected by gas chromatography technique in the patient's urine. Biopsy of skin lesions showed acute necrotising neutrophilic vasculitis involving small and medium vessels in both dermis and subcutaneous tissue with fibrin thrombi and fibrinoid necrosis. A diagnosis of levamisole-induced vasculitis with ecchymosis and necrosis syndrome was made from contamination of cocaine with levamisole. Levamisole has been identified as a contaminant in 70% of cocaine seized in the USA.1 The prevalence of levamisole as a contaminant of cocaine may be  related to its similar appearance to cocaine and stimulant effects from dopamine release. It is detected by gas chromatography mass spectroscopy technique in urine specimens.2 Toxicity causes cutaneous, haematological and neurological manifestations. The spectrum of cutaneous involvement includes development of purpuric papules, ecchymosis, skin necrosis leading to ulceration and secondary infection. Bilateral ear involvement, especially helical margins, is seen in the majority of patients.3

    Figure 1
    Figure 1

    Skin ecchymosis and retiform purpurae.

    Figure 3
    Figure 3

    Necrosis of helical rims of pinnae.

    Learning points

    • Identify complications of cocaine use.

    • Differential diagnosis of causes for necrotising vasculitis.

    References

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      Centers for Disease Control and Prevention. Agranulocytosis associated with cocaine use—four States, March 2008–November 2009. MMWR Morb Mortal Wkly Rep 2009;58:1381–5.
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      1. Trehy ML,
      2. Brown DJ,
      3. Woodruff JT,
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      . Determination of levamisole in urine by gas chromatography-mass spectrometry. J Anal Toxicol 2011;35:545–50.
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    3. ↵
      1. Jacob RS,
      2. Silva CY,
      3. Powers JG,
      4. et al
      . Levamisole-induced vasculopathy: a Report of 2 cases and a novel histopathologic finding. Am J Dermatopathol 2011;35:208–13.
      OpenUrl
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    Footnotes

    • Competing interests None.

    • Patient consent Obtained.