Levamisole-Induced Vasculitis: A Characteristic Cutaneous Vasculitis Associated With Levamisole-Adulterated Cocaine

Abstract

Levamisole-induced vasculitis is a characteristic cutaneous vasculitis syndrome associated with the use of levamisole-adulterated cocaine. Patients will typically present with a painful, purpuric rash in a retiform or stellate pattern with or without central necrosis involving the extremities, trunk, nasal tip, digits, cheeks, and/or ears. A history of cocaine abuse can be elicited. Histologic features include microvascular thrombi and/or leukocytoclastic vasculitis involving small vessels of the superficial and deep dermis. Epidermal involvement is variably seen. Laboratory findings include leukopenia, neutropenia (including agranulocytosis), elevated erythrocyte sedimentation rate, normal coagulation studies, and positive autoantibodies including perinuclear and cytoplasmic antineutrophil cytoplasmic antibodies, antinuclear antibody, and lupus anticoagulant. Differential diagnosis includes other microscopic vasculitides, and clinical and laboratory correlation with histologic findings is essential. Lesions typically resolve with the cessation of cocaine use. Because of the treatment implications and rising incidence of this entity, rapid and accurate diagnosis is essential.

Severe ANCA Associated Vasculitis in the Setting of Cocaine Abuse: A Case Report

“…Levamisole induced AAV is a relatively new entity with cases first being documented as early as 2009; its clinical presentation being a tender, purpuric rash in extremities, trunk, digits and nasal tip [4]. Considering that in 2016, 93% of the cocaine seized by the US Drug Enforcement Agency was cut with Levamisole and/or levamisole mixtures [5], and that the patient's initial clinical presentation was similar to other cases described in literature; in retrospect, levamisole induced AAV is the likely culprit for this patient's initial symptoms in 2010.…”

Vanishing vasculitis: a case of acute necrotic skin findings without pathologic features of vasculitis from adulterated cocaine

“…This is because, in the USA, it is now estimated that about 70% of the cocaine is adulterated with levamisole as it not only adds volume to the drug but is also believed to potentiate psychotropic properties of the cocaine [2]. …”

“…Levamisole-induced lesions have a predilection for the ears and extremities. Also, the most pathognomonic lesions are those on the ears [2]. …”

“…However, severe cases can involve deeper skin structures requiring skin grafts [2]. Neutropenia and agranulocytosis can either occur in isolation or precede cutaneous vasculopathy.…”

“…In some cases, due to necrosis and extensive wound formation, patients can also develop superimposed infection; in such cases, surgical debridement and skin grafting prove beneficial. It is important to note that infections can be more dreadful as patients are already in an immunocompromised state due to neutropenia that follows the use of levamisole [2]. …”