Painful Violaceous Purpura on a 44-Year-Old Woman

Bullous Retiform Purpura on the Ears and Legs

“…Although this reaction pattern has an extensive differential, in this clinical setting with associated cocainepositive urine toxicologic analysis, perinuclear antineutrophil cytoplasmic antibodies (p-ANCA), and leukopenia, the histopathologic findings were consistent with levamisoleinduced vasculopathy (LIV). 1,2 Although not specific, leukocytoclastic vasculitis and thrombotic vasculopathy have been reported as the classic histopathologic findings of LIV. In addition, interstitial and perivascular neovascularization have been reported as a potential histopathologic finding associated with this entity but was not seen in our case.…”

“…3 Levamisole is an anthelminthic agent used to adulterate cocaine, a practice first noted in 2003 with increasing incidence. 1 Both levamisole and cocaine stimulate the sympathetic nervous system by increasing dopamine in the euphoric areas of the brain. 1,3 By combining the 2 substances, preparation costs are reduced and stimulant effects are enhanced.…”

“…1 Both levamisole and cocaine stimulate the sympathetic nervous system by increasing dopamine in the euphoric areas of the brain. 1,3 By combining the 2 substances, preparation costs are reduced and stimulant effects are enhanced. It is estimated that 69% to 80% of cocaine in the United States is contaminated with levamisole.…”

“…The half-life of levamisole is relatively short (estimated at 5.6 hours) and is found in urine samples approximately 3% of the time. 1,3,6 The volatile diagnostic characteristics of levamisole make concrete laboratory confirmation difficult. Although a skin biopsy can be helpful to rule out other causes of vasculitislike presentations, it is not specific for LIV.…”