Plasmapheresis and Steroid Treatment of Levamisole-Induced Vasculopathy and Associated Skin Necrosis in Crack/Cocaine Users

Abstract

Levamisole is frequently added to crack/cocaine; we report three patients who developed vascular lesions and skin necrosis after using cocaine/levamisole. These improved with plasmapheresis and immunosuppression as well as abstention from the drugs; one patient with severe disease required débridement and skin grafting.

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

“…7,11,12 The role of corticosteroids is not well defined; these have not definitively been shown to improve or accelerate healing. 7,11,27 Use of plasmapheresis has been investigated but only in case reports. 27 Some patients develop bacterial superinfection of the lesions after rupture of bullae, leading to complications such as extensive wound infections requiring surgical debridement and subsequent skin grafting.…”

“…27 Some patients develop bacterial superinfection of the lesions after rupture of bullae, leading to complications such as extensive wound infections requiring surgical debridement and subsequent skin grafting. 12,27 This is further exacerbated by the fact that neutropenia and leukopenia is common in these patients, causing an induced immune-suppressed state. There are some reports of patients with such severe wounds that they necessitate amputation.…”

Suspected Infective Endocarditis Finally Turned Out to Be Levamisole-Induced Vasculitis: A Case Report and Review of Literature

“…Furthermore, since the most reported cases do not have internal organ involvement, the steroid is not needed and may in fact be harmful because of serious side effects [9]. There are reports of the use of plasmapheresis in case reports but we currently have no enough data to support or preclude its use [10]. In our patient, no corticosteroid or plasmapheresis was used and the skin lesions improved with the discontinuation of cocaine.…”

Breaking-Out Bad: A Case of Levamisole-Induced Vasculitis

“…Certain cases involving significant necrosis, neutropenia, continued cocaine use, or worsening disease despite treatment have been treated with steroids or other immunosuppressive agents, as well as anticoagulation for thrombotic complications; however, there is no evidence to suggest this portends a better outcome. 12 In the case of severe cutaneous involvement, debridement, grafting, and appropriate management in a burn unit is generally advisable.…”