Case and Research Letter
Leukocytoclastic vasculitis related to cocaine-adulterated levamisole
Vasculitis leucocitoclástica relacionada con cocaína adulterada con levamisol
A. Imbernón-Moya
, R. Chico, I. de la Hera, M.Á. Gallego-Valdés
Corresponding author
Servicios de Dermatologia, del Hospital Universitario Severo Ochoa, Avda. de Orellana s/n. 28911 – Leganés (Madrid), Spain
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Imbernón-Moya, R. Chico, I. de la Hera, M.Á. Gallego-Valdés" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Imbernón-Moya" "email" => array:1 [ 0 => "adrian_imber88@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "R." "apellidos" => "Chico" ] 2 => array:2 [ "nombre" => "I." "apellidos" => "de la Hera" ] 3 => array:2 [ "nombre" => "M.Á." "apellidos" => "Gallego-Valdés" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicios de Dermatologia, del Hospital Universitario Severo Ochoa, Avda. de Orellana s/n. 28911 – Leganés (Madrid), Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Vasculitis leucocitoclástica relacionada con cocaína adulterada con levamisol" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1245 "Ancho" => 701 "Tamanyo" => 169186 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patches with a necrotic central area and erythematous borders on the right ear.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cocaine consumption has been increasing around the world in recent years and the associated complications are thus becoming more and more common.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Levamisole is often found in contaminated cocaine and can increase the length and intensity of the stimulant effect of this recreational drug.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case description</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 47-year-old man with no medical background of note attended the dermatology department for a 1-month history of painful skin lesions on both ears. He otherwise felt well. On further questioning, he denied having taken any new or different prescription drugs and reported no prodromal symptoms. However, he did state he was a smoker and a user of cocaine since the age of 25 years; of note, he had sniffed cocaine 3 days before the onset of the lesions.</p><p id="par0015" class="elsevierStylePara elsevierViewall">At presentation, symmetrical, bilateral erythematous-violaceous patches were observed on his ears (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and on the lateral walls of the abdomen (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Over the following days, the lesions became infiltrated edematous papules and plaques that subsequently progressed to ulcerated necrotic plaques with an erythematous halo.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Full blood count and biochemistry were normal, including liver and kidney function tests. Urinalysis was unremarkable. Autoimmune screening revealed a polyclonal hypergammaglobulinemia, positive anticardiolipin M (48<span class="elsevierStyleHsp" style=""></span>U/ml), and positive antinuclear antibodies (titer, 1:160) with a speckled pattern. Complement was normal and the extractable nuclear antibodies panel (Smith, ribonucleoprotein, Ro, La, Scl-70, Jo-1), double-stranded DNA, antineutrophil cytoplasmic antibodies (ANCA), and cryoglobulins were negative. Serology for human immunodeficiency virus (HIV), hepatitis C virus (HCV) and hepatitis B virus (HBV) were negative and coagulation studies were normal. Chest X-ray did not show any relevant features. A full-thickness skin biopsy showed a leukocytoclastic vasculitis of the superficial and deep dermal and subcutaneous vascular plexuses, with some thrombotic features (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Urine drug screening was not performed. Based on these tests, we made a diagnosis of cutaneous leukocytoclastic vasculitis secondary to the use of levamisole-contaminated cocaine. The patient was treated with topical copper sulfate 1:1000 and betamethasone dipropionate, 0.05%, for 2 weeks, with an excellent response and complete clearance of the lesions without scarring, and no new lesions developed. The patient did not attend follow-up appointments.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Skin lesions are rare after cocaine use; they usually develop 1–4 days after exposure to the drug. The clinical spectrum can be broad and may be associated with digital vasospasm, Raynaud phenomenon, livedo reticularis, Buerger's disease, urticarial vasculitis, bullous diseases, acral ulcers, gangrene, and small and medium vessel vasculitis.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Lesions usually have a rapid onset, with a painful violaceous rash that tends to ulcerate and become necrotic, typically affecting the face (ears and cheeks) and lower legs. Systemic complications are uncommon except for joint pain, which is common.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3–9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The pathogenesis of the condition is largely unknown, although some research points to tissue ischemia caused by blood vessel constriction, direct or indirect blood vessel damage induced by immune complexes, or thrombosis.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Histopathologic features can include vascular thrombosis and leukocytoclastic vasculitis, with or without fibrinoid necrosis. These are nonspecific features and can be found in many other disorders.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3,5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Patients may develop antiphospholipid antibodies (namely IgM anticardiolipin and lupus anticoagulant) and ANCA with a cytoplasmic (c-ANCA) or perinuclear (p-ANCA) pattern. C-ANCA antibodies almost exclusively target proteinase 3 (PR3) antigen whereas p-ANCA antibodies can bind multiple antigens, including myeloperoxidase, lactoferrin, human neutrophil elastase (HNE), and PR3; HNE is specifically targeted after cocaine use,<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3,4,10</span></a> and this may induce neutropenia in some patients,<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,9</span></a> which can lead to confusion with other vasculitides, particularly with the ANCA-positive vasculitides (polyarteritis nodosa, microscopic polyangiitis, eosinophilic granulomatosis with polyangiitis, granulomatosis with polyangiitis). As no pathognomonic laboratory or histopathologic criteria exist, the diagnosis is purely clinic and is made by exclusion. A detailed clinical history and a high level of clinical suspicion are paramount.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3–9</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The diagnostic approach to cases of suspected cocaine-induced cutaneous vasculitis should include complete blood count, biochemistry including liver and kidney function tests, erythrocyte sedimentation rate, urinalysis, chest X-ray, fecal occult blood, full thickness skin biopsy, antiphospholipid antibodies, coagulation studies including homocysteine and proteins C and S, cryoglobulins, serum ANCA and ANA antibodies, double-stranded DNA antibodies, rheumatoid factor and complement levels, and serology for HIV, HBV, and HCV. Other tests such as blood, urine, or skin microbiology should be performed as required.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3,4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The skin lesions usually resolve within 2–3 weeks after cessation of cocaine use. Normalization of laboratory tests can take 2–14 months, though the neutropenia recovers fully in less than 10 days.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3,5,7,8</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">There is no consensus regarding treatment of this condition. Obviously, removal of the cause is the most important measure, together with symptom relief. Good clinical outcomes have been reported with the use of nonsteroidal anti-inflammatory drugs for arthralgia and colchicine, dapsone, oral antihistamines, and pentoxifylline for the skin lesions.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3,4</span></a> Systemic corticosteroids have not been shown to be effective.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case description" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1245 "Ancho" => 701 "Tamanyo" => 169186 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patches with a necrotic central area and erythematous borders on the right ear.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 535 "Ancho" => 949 "Tamanyo" => 81173 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Patch with a necrotic central area and erythematous border on the abdomen.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1827 "Ancho" => 901 "Tamanyo" => 652470 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Leukocytoclastic vasculitis of the superficial and deep dermal vascular plexuses, with some thrombotic features. Hematoxylin and eosin, original magnification ×4. (B) Leukocytoclastic vasculitis with some thrombotic features. Hematoxylin and eosin, original magnification ×20.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The head, neck, and systemic manifestations of levamisole-adulterated cocaine use" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K.R. Magliocca" 1 => "N.A. Coker" 2 => "S.R. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 8 | 15 |
| 2024 October | 67 | 57 | 124 |
| 2024 September | 78 | 21 | 99 |
| 2024 August | 99 | 66 | 165 |
| 2024 July | 77 | 33 | 110 |
| 2024 June | 88 | 43 | 131 |
| 2024 May | 69 | 37 | 106 |
| 2024 April | 82 | 18 | 100 |
| 2024 March | 103 | 29 | 132 |
| 2024 February | 78 | 31 | 109 |
| 2024 January | 68 | 35 | 103 |
| 2023 December | 73 | 18 | 91 |
| 2023 November | 99 | 30 | 129 |
| 2023 October | 78 | 28 | 106 |
| 2023 September | 75 | 49 | 124 |
| 2023 August | 44 | 14 | 58 |
| 2023 July | 70 | 45 | 115 |
| 2023 June | 59 | 41 | 100 |
| 2023 May | 112 | 35 | 147 |
| 2023 April | 71 | 27 | 98 |
| 2023 March | 56 | 32 | 88 |
| 2023 February | 43 | 19 | 62 |
| 2023 January | 53 | 22 | 75 |
| 2022 December | 63 | 29 | 92 |
| 2022 November | 32 | 29 | 61 |
| 2022 October | 37 | 16 | 53 |
| 2022 September | 16 | 22 | 38 |
| 2022 August | 17 | 27 | 44 |
| 2022 July | 22 | 25 | 47 |
| 2022 June | 15 | 23 | 38 |
| 2022 May | 45 | 35 | 80 |
| 2022 April | 46 | 27 | 73 |
| 2022 March | 48 | 44 | 92 |
| 2022 February | 57 | 21 | 78 |
| 2022 January | 80 | 37 | 117 |
| 2021 December | 60 | 28 | 88 |
| 2021 November | 53 | 42 | 95 |
| 2021 October | 94 | 53 | 147 |
| 2021 September | 63 | 45 | 108 |
| 2021 August | 87 | 20 | 107 |
| 2021 July | 70 | 21 | 91 |
| 2021 June | 43 | 17 | 60 |
| 2021 May | 48 | 41 | 89 |
| 2021 April | 99 | 67 | 166 |
| 2021 March | 66 | 23 | 89 |
| 2021 February | 73 | 18 | 91 |
| 2021 January | 39 | 17 | 56 |
| 2020 December | 26 | 14 | 40 |
| 2020 November | 31 | 19 | 50 |
| 2020 October | 23 | 11 | 34 |
| 2020 September | 34 | 10 | 44 |
| 2020 August | 15 | 22 | 37 |
| 2020 July | 20 | 14 | 34 |
| 2020 June | 29 | 24 | 53 |
| 2020 May | 16 | 17 | 33 |
| 2020 April | 29 | 9 | 38 |
| 2020 March | 21 | 13 | 34 |
| 2020 February | 6 | 0 | 6 |
| 2020 January | 5 | 0 | 5 |
| 2019 December | 7 | 0 | 7 |
| 2019 November | 4 | 0 | 4 |
| 2019 September | 8 | 0 | 8 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 6 | 0 | 6 |
| 2019 May | 7 | 1 | 8 |
| 2019 April | 5 | 6 | 11 |
| 2019 March | 3 | 0 | 3 |
| 2019 February | 5 | 0 | 5 |
| 2019 January | 4 | 0 | 4 |
| 2018 December | 2 | 0 | 2 |
| 2018 November | 1 | 0 | 1 |
| 2018 October | 4 | 0 | 4 |
| 2018 September | 3 | 0 | 3 |
| 2018 February | 11 | 3 | 14 |
| 2018 January | 29 | 4 | 33 |
| 2017 December | 22 | 6 | 28 |
| 2017 November | 19 | 9 | 28 |
| 2017 October | 21 | 7 | 28 |
| 2017 September | 17 | 5 | 22 |
| 2017 August | 15 | 3 | 18 |
| 2017 July | 29 | 10 | 39 |
| 2017 June | 25 | 9 | 34 |
| 2017 May | 18 | 2 | 20 |
| 2017 April | 14 | 4 | 18 |
| 2017 March | 16 | 15 | 31 |
| 2017 February | 12 | 4 | 16 |
| 2017 January | 9 | 8 | 17 |
| 2016 December | 22 | 11 | 33 |
| 2016 November | 32 | 30 | 62 |
Show all
