A Case of Levamisole-Induced Systemic Vasculitis and Cocaine-Induced Midline Destructive Lesion

Abstract

We describe a case of antineutrophil cytoplasmic antibody-positive vasculitis from levamisole-tainted cocaine with concomitant cocaine-induced midline destructive lesions of the palate and nasal septum. The diagnosis was confirmed after extensive clinical, laboratory, pathologic, and radiographic testing. Timely recognition of this clinical entity is critical to avoid misdiagnosis and unnecessary treatment with potentially harmful cytotoxic agents. Given the high rate of levamisole contamination within the nation's cocaine supply, clinicians should be alerted to this emerging health threat.

Levamisole-Contaminated Cocaine Use in HIV-Infected and Uninfected Unstably Housed Women

“…While neutropenia has been cited as a concern in case reports of persons seeking treatment for conditions linked to levamisole, 9,14,16,35,36 we did not find significant differences in neutrophil count by cocaine and levamisole status (Table 2). Furthermore, adjusted models suggested mediation of cocaine/ levamisole effects on white blood cell count by lymphocyte count, but not by neutrophil count (Table 3).…”

Differential Diagnosis of Necrotizing Sinonasal Lesions

“…[39][40][41][42][43] Short-term cocaine use can lead to mucosal ulceration and necrosis. Long-term use has been associated with ischemia of not only the mucosal tissue but cartilage and bone, resulting in midline deformity and septal/palatal perforations.…”

“…Long-term use has been associated with ischemia of not only the mucosal tissue but cartilage and bone, resulting in midline deformity and septal/palatal perforations. [39][40][41][42][43] Histologically, one can see significant granulomatous inflammation, infarction, necrosis, and giant cell reaction (Figure 4, A through C). Necrotizing vasculitis may be evident.…”

“…As a result, CIMDL shows clinical and histopathologic overlap with other midline destructive lesions, particularly GPA. [39][40][41][42][43] Interestingly, CIMDL can be associated with the presence of ANCA, making distinction from overlapping vasculitic syndromes difficult. The etiology of CIMDL is not clear.…”

“…[39][40][41][42][43] The pathogenesis of cocaine in the development of CIMDL likely involves vasoconstriction resulting in ischemia and resulting mucosal and bone/cartilage necrosis, but recent evidence also implicates the possibility of levamisole (which is a known contaminant in cocaine) playing a role in CIMDL. 43 It is believed that levamisole induces the autoimmune reaction because this agent has been associated with necrotizing vasculitis in other areas of the body. Most importantly, although CIMDL may be associated with the presence of ANCA, CIMDL does not respond to immunosuppressive therapy like GPA.…”