Case and research letters
Leukocytoclastic Vasculitis Related to Cocaine Use
Vasculitis leucocitoclástica asociada a consumo de cocaína
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Salas-Espíndola, A. Peniche-Castellanos, I. López-Gehrke, P. Mercadillo-Pérez" "autores" => array:4 [ 0 => array:3 [ "nombre" => "Y." "apellidos" => "Salas-Espíndola" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "A." "apellidos" => "Peniche-Castellanos" "email" => array:1 [ 0 => "amelia_peniche@yahoo.com.mx" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "I." "apellidos" => "López-Gehrke" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "P." "apellidos" => "Mercadillo-Pérez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital General de México, México, D.F" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatopatología, Hospital General de México, México, D.F" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Vasculitis leucocitoclástica asociada a consumo de cocaína" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 876 "Ancho" => 951 "Tamanyo" => 282714 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histopathology: mainly neutrophilic, abundant perivascular inflammatory infiltrate that infiltrates and partially destroys blood vessel walls; prominent leukocytoclasis and multiple foci of vascular thrombosis (periodic acid-Schiff, original magnification x40).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Vasculitis is a rare complication of cocaine abuse and poses significant diagnostic and management problems. We report a case of this type of vasculitis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 45-year-old woman with a history of cocaine abuse from age 23 years consulted because of a 20-day history of a widespread skin condition that affected practically the whole body surface, was accompanied by fever and intense pain, and prevented her from walking. At the time of admission, the patient was underweight, had facies dolorosa, normal vital signs, and dry mucosas. Physical examination revealed multiple ulcers of varying shape and size, with a purulent, foul-smelling exudate; several were covered by necrotic slough (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Additional tests, based on a suspected clinical diagnosis of systemic vasculitis, gave the following results: white blood cell count, 12 500/μL; hemoglobin, 9.8<span class="elsevierStyleHsp" style=""></span>g/dL; reactive thrombocytosis, 658 000/μL; hypoalbuminemia, 2.0<span class="elsevierStyleHsp" style=""></span>g/dL; alanine aminotransferase, 68 U/L; aspartate aminotransferase, 62 U/L; γ-glutamyltransferase, 181 U/L; alkaline phosphatase, 326 U/L; creatinine clearance, 88.3<span class="elsevierStyleHsp" style=""></span>mL/min with renal function of 86.6%; C-reactive protein, 1.40<span class="elsevierStyleHsp" style=""></span>mg/dL; a negative Venereal Disease Research Laboratory test, negative rheumatoid factor; antineutrophil cytoplasmic antibodies (c-ANCA), 1:40; perinuclear (p) ANCA, 1:2560 U/mL; p-ANCA antilactoferrin, 48.2 U/mL; culture of the skin exudate, <span class="elsevierStyleItalic">Escherichia coli</span>; positive total hepatitis A virus antibody; negative anti-hepatitis B and anti-hepatitis C virus antibodies; negative human immunodeficiency virus (enzyme-linked immunosorbent assay). Skin biopsy revealed leukocytoclastic vasculitis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The otorhinolaryngology department reported perforation of the cartilaginous portion of the nasal septum, confirmed by computed tomography, but biopsy of the nasal mucosa only revealed chronic inflammation. The psychiatry department diagnosed the patient as having a mixed personality disorder and treatment was initiated with amitriptyline, perphenazine, and diazepam. The general surgery department then performed surgical debridement of the ulcers and escharectomy. The patient was treated with antibiotics (trimethoprim-sulfamethoxazole, 160/800<span class="elsevierStyleHsp" style=""></span>mg, administered intravenously every 12<span class="elsevierStyleHsp" style=""></span>hours for 14 days), analgesics, and thalidomide (100<span class="elsevierStyleHsp" style=""></span>mg/d); prednisone (0.5<span class="elsevierStyleHsp" style=""></span>mg/kg) was added after achieving control of the infection. The response was satisfactory and the patient was discharged after 37 days, with the presence of granulation tissue and partial reepithelialization of the ulcerated areas. Diagnosis at discharge was cocaine-related vasculitis based on the clinical findings, histopathological study, the positivity of serum markers (p-ANCA and lactoferrin), a history of long-term consumption of the drug, and the exclusion of other causes.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Follow-up confirmed the reepithelialization of most lesions, which developed into hypertrophic scars and retractile keloids, currently awaiting surgical treatment by the plastic surgery department (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Cocaine consumption is increasing worldwide, leading to a rise in related diseases. The spectrum of skin lesions caused by cocaine is broad and has been related to digital vasospasm, bullous diseases, small- and medium-vessel vasculitis, which present as purpura, necrotizing vasculitis, urticarial vasculitis, ulcers, livedo reticularis, Buerger disease, pyoderma gangrenosum, and gangrene.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Some authors hold levamisole, an adulterant found in the end product, responsible for the damage in cases involving microvascular thrombosis and neutropenia.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> There are reports of cocaine consumption in patients with Wegener granulomatosis,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and since both may cause midline destructive lesions of the face, distinguishing between them can be difficult. In our patient, the absence of granulomatous vasculitis of the respiratory tract, renal involvement, and high titers of c-ANCA enabled us to rule out this possibility.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The study protocol for cocaine-related vasculitis is identical to drug-related vasculitis and includes a blood count, erythrocyte sedimentation rate, routine biochemistry, chest x-ray, urinalysis, liver function tests, and fecal occult blood. More specific studies should subsequently be considered, such as histopathology with or without direct immunofluorescence, anticardiolipin antibodies, homocysteine levels, proteins S and C, and cryoglobulins. Serum levels of ANCA, antinuclear antibodies, rheumatoid factor, complement, and hepatitis B and C virus antibodies should also be determined, together with human immunodeficiency virus serology.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The case presented here was a drug-dependent patient whose clinical lesions were compatible with necrotizing vasculitis confirmed by histopathology, with a diagnosis of an ANCA-positive cutaneous vasculitis (p-ANCA, 1:2560 U/mL, antilactoferrin antibodies, 48.2 U/mL). The differential diagnosis included other forms of ANCA-positive small-vessel vasculitis. The role of ANCA in the pathogenesis of vasculitis is still unclear. One hypothesis suggests that ANCA stimulate neutrophil degranulation, activation, and apoptosis, leading to direct and indirect endothelial damage.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Drug-induced ANCA show a perinuclear fluorescence pattern (p-ANCA) and positivity to several antigens (myeloperoxidase, cathepsin G, proteinase 3, azurocidin, bactericidal/permeability-increasing protein, lactoferrin, and human neutrophil elastase). Reports in the literature suggest that the presence of lactoferrin and human neutrophil elastase supports the diagnosis of a cocaine-related syndrome.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The management of these patients is still a matter of debate, but good outcomes have been reported with the use of systemic steroids, nonsteroidal immunosuppressants, antihistamines, dapsone, pentoxifylline, and intravenous immunoglobulin.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Our patient stopped taking cocaine and was treated with thalidomide and systemic steroids. Although the outcome was excellent, significant scarring could not be avoided.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Salas-Espíndola Y, et al. Vasculitis leucocitoclástica asociada a consumo de cocaína. Actas Dermosifiliogr.2011;102:825-826.</p>" ] ] "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" => 1532 "Ancho" => 951 "Tamanyo" => 214306 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Photograph at presentation. Ulcers with a purulent exudate and covered with necrotic slough.</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" => 876 "Ancho" => 951 "Tamanyo" => 282714 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histopathology: mainly neutrophilic, abundant perivascular inflammatory infiltrate that infiltrates and partially destroys blood vessel walls; prominent leukocytoclasis and multiple foci of vascular thrombosis (periodic acid-Schiff, original magnification x40).</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" => 697 "Ancho" => 1301 "Tamanyo" => 131313 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Photograph at 7 months of follow-up. There is reepithelialization of the lesions and scarring.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Vasculitis: a collection of pearls and myths" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.H. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 15 | 11 | 26 |
| 2024 Octubre | 145 | 41 | 186 |
| 2024 Septiembre | 179 | 32 | 211 |
| 2024 Agosto | 227 | 48 | 275 |
| 2024 Julio | 244 | 49 | 293 |
| 2024 Junio | 189 | 46 | 235 |
| 2024 Mayo | 249 | 34 | 283 |
| 2024 Abril | 125 | 26 | 151 |
| 2024 Marzo | 190 | 43 | 233 |
| 2024 Febrero | 164 | 29 | 193 |
| 2024 Enero | 236 | 43 | 279 |
| 2023 Diciembre | 165 | 33 | 198 |
| 2023 Noviembre | 165 | 40 | 205 |
| 2023 Octubre | 163 | 41 | 204 |
| 2023 Septiembre | 96 | 41 | 137 |
| 2023 Agosto | 109 | 28 | 137 |
| 2023 Julio | 118 | 50 | 168 |
| 2023 Junio | 94 | 39 | 133 |
| 2023 Mayo | 102 | 45 | 147 |
| 2023 Abril | 91 | 32 | 123 |
| 2023 Marzo | 123 | 25 | 148 |
| 2023 Febrero | 126 | 34 | 160 |
| 2023 Enero | 102 | 39 | 141 |
| 2022 Diciembre | 80 | 37 | 117 |
| 2022 Noviembre | 70 | 25 | 95 |
| 2022 Octubre | 42 | 21 | 63 |
| 2022 Septiembre | 48 | 39 | 87 |
| 2022 Agosto | 33 | 36 | 69 |
| 2022 Julio | 32 | 31 | 63 |
| 2022 Junio | 22 | 37 | 59 |
| 2022 Mayo | 88 | 41 | 129 |
| 2022 Abril | 117 | 49 | 166 |
| 2022 Marzo | 119 | 62 | 181 |
| 2022 Febrero | 114 | 36 | 150 |
| 2022 Enero | 116 | 41 | 157 |
| 2021 Diciembre | 71 | 43 | 114 |
| 2021 Noviembre | 89 | 43 | 132 |
| 2021 Octubre | 81 | 59 | 140 |
| 2021 Septiembre | 63 | 47 | 110 |
| 2021 Agosto | 97 | 41 | 138 |
| 2021 Julio | 84 | 34 | 118 |
| 2021 Junio | 52 | 33 | 85 |
| 2021 Mayo | 50 | 55 | 105 |
| 2021 Abril | 112 | 71 | 183 |
| 2021 Marzo | 116 | 24 | 140 |
| 2021 Febrero | 64 | 39 | 103 |
| 2021 Enero | 65 | 29 | 94 |
| 2020 Diciembre | 63 | 20 | 83 |
| 2020 Noviembre | 29 | 27 | 56 |
| 2020 Octubre | 28 | 18 | 46 |
| 2020 Septiembre | 50 | 28 | 78 |
| 2020 Agosto | 21 | 21 | 42 |
| 2020 Julio | 35 | 22 | 57 |
| 2020 Junio | 39 | 28 | 67 |
| 2020 Mayo | 35 | 27 | 62 |
| 2020 Abril | 37 | 20 | 57 |
| 2020 Marzo | 34 | 22 | 56 |
| 2020 Febrero | 6 | 14 | 20 |
| 2020 Enero | 3 | 12 | 15 |
| 2019 Diciembre | 8 | 13 | 21 |
| 2019 Noviembre | 4 | 5 | 9 |
| 2019 Octubre | 0 | 4 | 4 |
| 2019 Septiembre | 8 | 6 | 14 |
| 2019 Agosto | 4 | 14 | 18 |
| 2019 Julio | 4 | 17 | 21 |
| 2019 Junio | 7 | 16 | 23 |
| 2019 Mayo | 4 | 26 | 30 |
| 2019 Abril | 4 | 14 | 18 |
| 2019 Marzo | 5 | 12 | 17 |
| 2019 Febrero | 0 | 6 | 6 |
| 2019 Enero | 5 | 3 | 8 |
| 2018 Diciembre | 2 | 2 | 4 |
| 2018 Noviembre | 7 | 4 | 11 |
| 2018 Octubre | 18 | 0 | 18 |
| 2018 Septiembre | 2 | 0 | 2 |
| 2018 Abril | 0 | 3 | 3 |
| 2018 Marzo | 2 | 0 | 2 |
| 2018 Febrero | 58 | 1 | 59 |
| 2018 Enero | 76 | 9 | 85 |
| 2017 Diciembre | 67 | 6 | 73 |
| 2017 Noviembre | 55 | 7 | 62 |
| 2017 Octubre | 40 | 5 | 45 |
| 2017 Septiembre | 69 | 11 | 80 |
| 2017 Agosto | 124 | 16 | 140 |
| 2017 Julio | 106 | 4 | 110 |
| 2017 Junio | 115 | 19 | 134 |
| 2017 Mayo | 94 | 13 | 107 |
| 2017 Abril | 79 | 11 | 90 |
| 2017 Marzo | 74 | 24 | 98 |
| 2017 Febrero | 173 | 12 | 185 |
| 2017 Enero | 81 | 11 | 92 |
| 2016 Diciembre | 78 | 11 | 89 |
| 2016 Noviembre | 131 | 16 | 147 |
| 2016 Octubre | 125 | 18 | 143 |
| 2016 Septiembre | 202 | 11 | 213 |
| 2016 Agosto | 195 | 11 | 206 |
| 2016 Julio | 96 | 13 | 109 |
| 2016 Junio | 18 | 0 | 18 |
| 2016 Mayo | 5 | 14 | 19 |
| 2016 Abril | 7 | 3 | 10 |
| 2016 Marzo | 6 | 1 | 7 |
| 2016 Febrero | 2 | 3 | 5 |
| 2016 Enero | 7 | 1 | 8 |
| 2015 Diciembre | 9 | 0 | 9 |
| 2015 Noviembre | 30 | 5 | 35 |
| 2015 Octubre | 14 | 1 | 15 |
| 2015 Septiembre | 9 | 4 | 13 |
| 2015 Agosto | 11 | 3 | 14 |
| 2015 Julio | 178 | 11 | 189 |
| 2015 Junio | 76 | 9 | 85 |
| 2015 Mayo | 117 | 18 | 135 |
| 2015 Abril | 75 | 10 | 85 |
| 2015 Marzo | 85 | 11 | 96 |
| 2015 Febrero | 89 | 14 | 103 |
| 2015 Enero | 58 | 17 | 75 |
| 2014 Diciembre | 79 | 17 | 96 |
| 2014 Noviembre | 67 | 17 | 84 |
| 2014 Octubre | 75 | 26 | 101 |
| 2014 Septiembre | 58 | 13 | 71 |
| 2014 Agosto | 75 | 23 | 98 |
| 2014 Julio | 45 | 19 | 64 |
| 2014 Junio | 82 | 22 | 104 |
| 2014 Mayo | 76 | 19 | 95 |
| 2014 Abril | 54 | 19 | 73 |
| 2014 Marzo | 67 | 20 | 87 |
| 2014 Febrero | 63 | 18 | 81 |
| 2014 Enero | 75 | 19 | 94 |
| 2013 Diciembre | 69 | 9 | 78 |
| 2013 Noviembre | 31 | 15 | 46 |
| 2013 Octubre | 23 | 1 | 24 |
| 2013 Septiembre | 14 | 8 | 22 |
| 2013 Agosto | 15 | 5 | 20 |
| 2013 Julio | 12 | 8 | 20 |
| 2013 Junio | 14 | 16 | 30 |
| 2013 Mayo | 15 | 3 | 18 |
| 2013 Abril | 15 | 8 | 23 |
| 2013 Marzo | 20 | 13 | 33 |
| 2013 Febrero | 45 | 5 | 50 |
| 2013 Enero | 78 | 4 | 82 |
| 2012 Diciembre | 43 | 11 | 54 |
| 2012 Noviembre | 0 | 1 | 1 |
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