Vasculitis due to levamisole-adulterated cocaine

Molecular Insights and Clinical Outcomes of Drugs of Abuse Adulteration: New Trends and New Psychoactive Substances

“…A total of 35 case reports of drug adulterants’ intoxications are included ( Table 2 ). Adulterants were analytically detected in biological matrices in only 15 cases and identified compounds were levamisole ( n = 7), 5F-MDMB-PICA ( n = 1); lead ( n = 1); sildenafil ( n = 1); etizolam and caffeine ( n = 1), and lysergic acid diethylamide (LSD) ( n = 4) [ 33 , 42 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 ]. In the remaining 20 cases, adulterants were only hypothesized based on the observed symptoms, disease or indirect sequelae or confiscated drug analysis.…”

Multiple cutaneous and mucosal lesions in a patient with cocaine-levamisole–induced vasculopathy syndrome

“…It was later used in humans for treatment of rheumatoid arthritis and colon cancer; however, it was removed from the US market in early 2000 when it was found to cause neutropenia and agranulocytosis. 1 It continues to be used in certain countries for its therapeutic benefit in childhood nephrotic syndrome. 2 Despite Food and Drug Administration regulation, levamisole has continuously been used as a cocaine adulterant due to its synergistic effect with cocaine, leading to an increase in dopamine transmission, and its physical similarity to cocaine, making the sample appear purer.…”

“…5,7 This leads to immune complex deposition with resultant vascular necrosis, inflammation, hemorrhage, and fibrin deposition. 1,6,11 Diagnosis requires the appropriate clinical history, classic cutaneous exam findings, leukopenia, ANCA positivity, and exclusion of infectious, idiopathic, or vasculitic entities. 5 Among all forms of vasculitis, distinction from granulomatosis with polyangiitis is critical for the choice and duration of immunosuppressive therapy.…”

“…5 Among all forms of vasculitis, distinction from granulomatosis with polyangiitis is critical for the choice and duration of immunosuppressive therapy. 1 Laboratory findings include high titers of perinuclear ANCA, which are identified in 90% of cases, with cytoplasmic ANCA also being identified in 54% of cases. 11 Approximately 50% of patients are PR-3 antibody positive, and nearly all are MPO antibody positive (MPO-myeloperoxidase).…”

“…Short courses of systemic corticosteroids and immunosuppressive medications were noted to be efficacious among patients who have evidence of systemic involvement or have severe skin lesions. 1,7,8,13 Patients with pulmonary hemorrhage may benefit from plasmapheresis in addition to immunosuppression. 7 With continued abstinence from cocaine use, neutropenia resolves within 5 to 10 days, skin lesions resolve within 2 to 3 weeks, and serologic markers resolve within 2 to 14 months.…”