Palpable Purpura Complicated by Streptococcal Toxic Shock Syndrome Resulting in Limb Necrosis and Amputation: A Case of Levamisole and Cocaine Coingestion

Abstract

Palpable purpura resulting from cocaine and levamisole coingestion has been reported with increasing frequency over the last several years as distribution of this drug combination becomes more universal. Toxicity from ingestion of this dangerous combination is difficult to diagnose due to the multitude of possible clinical presentations, variety of possible adulterants, and elusive nature of levamisole given its short half-life and limited availability of detection methods. Levamisole is a chemotherapeutic and immunomodulatory agent currently marketed as a veterinary anthelmintic. We describe the case of a 48-year-old woman admitted to our intensive care unit with a diagnosis of streptococcal toxic shock syndrome (STSS), confirmed from fluid taken from an elbow lesion that grew Streptococcus pyogenes. She was noted to have bullae of the elbow and diffuse purpura with necrotic centers covering a large portion of her body (trunk, legs, arms, back, toes, fingers, and tip of nose). On further evaluation, she was found to have ingested levamisole-tainted cocaine. The patient's complications related to either cocaine and levamisole coingestion or STSS included thrombocytopenia, acute renal failure, and limb necrosis. Thrombocytopenia gradually improved upon treatment with prednisone, and acute renal failure improved with intravenous fluid resuscitation; however, she subsequently required several appendage amputations due to severe gangrene. Clinicians must have high suspicion for ingestion of this drug combination and request prompt testing of urine samples for levamisole if a patient who admits to illicit drug use presents with purpuric or necrotic skin lesions.

Levamisole‐induced occlusive necrotising vasculitis in cocaine abusers: an unusual cause of skin necrosis and neutropenia

“…Another possible aetiopathologic mechanism for the skin lesions with thrombotic vasculopathy is drug‐induced antiphospholipid antibodies. Anti‐cardiolipin antibodies were negative in all three cases reported here, but other groups have found transient positivity of antiphospholipid antibodies and have postulated that these antibodies may play a pathologic role in this disease (6,32,35,40,41).…”

“…ANCA positive, midline granulomatous, perforating lesions of the oral and nasal cavities in chronic nasal cocaine users are known mimics of granulomatosis with polyangiitis (Wegener's granulomatosis) but are differentiated on the basis of ANCA reactivity to HNE in patients with cocaine exposure (13)(14)(15)(16)(17). The currently reported constellation of symptoms and signs with ischaemic skin lesions at unusual sites associated with neutropenia represents a new entity in the cocaine disease spectrum (5)(6)(7)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35) that is important for wound specialists to be aware of.…”

Levamisole-Adulterated Cocaine Induced Skin Necrosis of Nose, Ears, and Extremities: Case Report

“…The exact mechanism by which levamisole affects the immune system is unclear, but it might increase neutrophil chemotaxis and activity, enhance T-cell immune responses, stimulate antibody production, up-regulate Toll-like receptors, or regulate other cytokine and intracellular signaling networks. 2 , 3 , 7 , 9 …”

“…It could also inhibit acetylcholinesterase activity, increase endogenous opioids, and increase dopamine concentration in the cerebral reward pathway. 1 , 3 …”

Cocaine-Induced Vasculitis: Clinical and Immunological Spectrum

“…The term LIVEN, levamisoleinduced vasculopathy, has recently been introduced. A novel histopathologic finding described in one case was the presence of extensive interstitial and perivascular neovascularization [40][41][42].…”