Case for Diagnosis
Retiform Purpura in Plaques
Placas purpúricas retiformes
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Márquez Balbás, A. Vidaller, F. Tresserra-Casas, J. González-Castro" "autores" => array:4 [ 0 => array:4 [ "nombre" => "G." "apellidos" => "Márquez Balbás" "email" => array:1 [ 0 => "40871gmb@comb.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Vidaller" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "F." "apellidos" => "Tresserra-Casas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "J." "apellidos" => "González-Castro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Departamento de Dermatología, Hospital Universitario Quirón Dexeus, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Medicina Interna, Hospital Universitario Quirón Dexeus, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Anatomía Patológica, Hospital Universitario Quirón Dexeus, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Placas purpúricas retiformes" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 800 "Ancho" => 1062 "Tamanyo" => 104051 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Patient History</span><p id="par0005" class="elsevierStylePara elsevierViewall">We report the case of a 41-year-old woman with no history of interest who was admitted with lesions that had first appeared 24<span class="elsevierStyleHsp" style=""></span>hours earlier. The lesions took the form of lividoid erythematous violaceous plaques that were retiform in appearance, with necrosis in the center in some cases. They were not painful on palpation and occurred successively on the arms, legs, and face (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The patient also reported pain in the wrists and hands. She was afebrile and denied having taken drugs or toxic substances or being bitten by insects.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Histopathology</span><p id="par0010" class="elsevierStylePara elsevierViewall">We performed a skin biopsy (<a class="elsevierStyleCrossRef" href="#fig0010">fig. 2</a>), which revealed an inflammatory dermal infiltrate consisting of abundant neutrophilic, polymorphonuclear leukocytes with nuclear remnants in the superficial and perivascular portion. We observed fibrinoid necrosis on the wall and thrombi in small vessels. The blood workup was remarkable for microcytic anemia with increased C-reactive protein levels (71.4<span class="elsevierStyleHsp" style=""></span>mg/L), anti-DNA 70<span class="elsevierStyleHsp" style=""></span>IU/mL, and perinuclear antineutrophil cytoplasmic antibodies (ANCA) 1:640. Urinalysis revealed the presence of cocaine.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What is your diagnosis?</span></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Diagnosis</span><p id="par0020" class="elsevierStylePara elsevierViewall">Cocaine-associated retiform purpura.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Clinical Course and Treatment</span><p id="par0025" class="elsevierStylePara elsevierViewall">The patient remained under observation and received systemic corticosteroids in hospital for 48<span class="elsevierStyleHsp" style=""></span>hours. The lesions improved before disappearing some days later. No new lesions appeared.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Comment</span><p id="par0030" class="elsevierStylePara elsevierViewall">Cocaine is widely consumed, and Spain has one of the highest consumption rates in the world. The drug is often mixed with other substances to increase volume. For many years, the substances used have been mannitol and lactose, local anesthetics, and more active drugs such as paracetamol and caffeine. Levamisole is widely used today and is frequently detected in cocaine throughout the world,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> reaching 70% in the United States. Levamisole is an antihelmintic and immunomodulatory drug that has been associated with the generation of antibodies such as antinuclear antibodies, anti-La antibodies, and ANCAs in patients with a specific immunogenetic profile. It has also been associated with neutropenia and agranulocytosis. It causes purpura on the skin,<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1–3</span></a> affecting mainly the ears, as observed in children who receive the drug to treat nephrotic syndrome.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Histopathology reveals a mixed pattern of leukocytoclastic vasculitis and microvascular thrombosis that is very characteristic of levamisole.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The differential diagnosis includes small vessel vasculitis, septic vasculitis, antiphospholipid syndrome, cryoglobulinemia, and necrosis induced by drugs such as ergotamine and cocaine. Wegener granulomatosis (WG) deserves special attention.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3,5</span></a> A positive cytoplasmic ANCA titer is a highly specific marker of WG.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> There are several reports of patients with midline destructive lesions, together with cutaneous vasculopathy and positive cytoplasmic ANCA titers, which are initially thought to be WG but are eventually associated with consumption of cocaine. Anti-4-hydroxynonenal (HNE) antibodies, a subtype of ANCA, could help to distinguish between both conditions. High anti-HNE titers would point to an association between the clinical findings and consumption of cocaine.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">We report the case of a woman with retiform skin lesions, joint pain, and increased perinuclear ANCA titers who had consumed cocaine. We suggest that her condition could have been caused by the levamisole used to adulterate the cocaine. Our hypothesis is strengthened by clinical, laboratory, and histopathological findings.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> The definitive proof is detection of levamisole in serum or urine, although this is difficult owing to the drug's short half-life, which is only 5-6<span class="elsevierStyleHsp" style=""></span>hours. Cocaine, on the other hand, remains detectable in urine for 4 days. Confirmation is also based on detection of anti-HNE antibodies, although the test may not always available in clinical laboratories.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Dermatologists should become familiarized with the clinical picture of cocaine-associated retiform purpura and be able to recognize this association in order to ensure cessation of the adulterated drug, which is key to satisfactory resolution of the process.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Patient History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Histopathology" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Diagnosis" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Clinical Course and Treatment" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Comment" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Márquez Balbás G, Vidaller A, Tresserra-Casas F, González-Castro J. lacas purpúricas retiformes. Actas Dermosifiliogr. 2015;106:831–832.</p>" ] ] "multimedia" => array:2 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 800 "Ancho" => 1062 "Tamanyo" => 104051 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 240 "Ancho" => 1000 "Tamanyo" => 109339 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Hematoxylin-eosin ×<span class="elsevierStyleHsp" style=""></span>10. B and C, Hematoxylin-eosin <span class="elsevierStyleHsp" style=""></span>×20.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cocaine-associated retiform purpura and neutropenia: Is levamisole the culprit?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J.M. Waller" 1 => "J.D. Feramisco" 2 => "L. Alberta-Wszolek" 3 => "T.H. McCalmont" 4 => "L.P. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 11 | 4 | 15 |
| 2024 Octubre | 95 | 45 | 140 |
| 2024 Septiembre | 90 | 34 | 124 |
| 2024 Agosto | 123 | 72 | 195 |
| 2024 Julio | 120 | 32 | 152 |
| 2024 Junio | 89 | 17 | 106 |
| 2024 Mayo | 87 | 30 | 117 |
| 2024 Abril | 85 | 120 | 205 |
| 2024 Marzo | 80 | 23 | 103 |
| 2024 Febrero | 84 | 33 | 117 |
| 2024 Enero | 89 | 34 | 123 |
| 2023 Diciembre | 102 | 20 | 122 |
| 2023 Noviembre | 105 | 23 | 128 |
| 2023 Octubre | 107 | 29 | 136 |
| 2023 Septiembre | 88 | 19 | 107 |
| 2023 Agosto | 73 | 17 | 90 |
| 2023 Julio | 109 | 33 | 142 |
| 2023 Junio | 83 | 20 | 103 |
| 2023 Mayo | 86 | 34 | 120 |
| 2023 Abril | 76 | 22 | 98 |
| 2023 Marzo | 84 | 26 | 110 |
| 2023 Febrero | 61 | 21 | 82 |
| 2023 Enero | 58 | 32 | 90 |
| 2022 Diciembre | 68 | 43 | 111 |
| 2022 Noviembre | 58 | 30 | 88 |
| 2022 Octubre | 58 | 27 | 85 |
| 2022 Septiembre | 69 | 39 | 108 |
| 2022 Agosto | 36 | 36 | 72 |
| 2022 Julio | 40 | 33 | 73 |
| 2022 Junio | 27 | 29 | 56 |
| 2022 Mayo | 99 | 40 | 139 |
| 2022 Abril | 106 | 36 | 142 |
| 2022 Marzo | 101 | 51 | 152 |
| 2022 Febrero | 80 | 22 | 102 |
| 2022 Enero | 104 | 26 | 130 |
| 2021 Diciembre | 54 | 37 | 91 |
| 2021 Noviembre | 74 | 39 | 113 |
| 2021 Octubre | 89 | 48 | 137 |
| 2021 Septiembre | 80 | 34 | 114 |
| 2021 Agosto | 95 | 29 | 124 |
| 2021 Julio | 76 | 41 | 117 |
| 2021 Junio | 72 | 24 | 96 |
| 2021 Mayo | 90 | 31 | 121 |
| 2021 Abril | 228 | 71 | 299 |
| 2021 Marzo | 172 | 63 | 235 |
| 2021 Febrero | 142 | 17 | 159 |
| 2021 Enero | 110 | 24 | 134 |
| 2020 Diciembre | 82 | 16 | 98 |
| 2020 Noviembre | 96 | 32 | 128 |
| 2020 Octubre | 48 | 9 | 57 |
| 2020 Septiembre | 50 | 17 | 67 |
| 2020 Agosto | 28 | 24 | 52 |
| 2020 Julio | 24 | 16 | 40 |
| 2020 Junio | 32 | 23 | 55 |
| 2020 Mayo | 19 | 19 | 38 |
| 2020 Abril | 30 | 25 | 55 |
| 2020 Marzo | 33 | 16 | 49 |
| 2020 Febrero | 3 | 1 | 4 |
| 2020 Enero | 0 | 6 | 6 |
| 2019 Diciembre | 4 | 4 | 8 |
| 2019 Noviembre | 0 | 2 | 2 |
| 2019 Octubre | 0 | 4 | 4 |
| 2019 Septiembre | 4 | 1 | 5 |
| 2019 Agosto | 0 | 2 | 2 |
| 2019 Julio | 0 | 3 | 3 |
| 2019 Junio | 2 | 1 | 3 |
| 2019 Mayo | 1 | 13 | 14 |
| 2019 Abril | 0 | 2 | 2 |
| 2019 Marzo | 2 | 3 | 5 |
| 2019 Enero | 2 | 0 | 2 |
| 2018 Diciembre | 1 | 0 | 1 |
| 2018 Noviembre | 1 | 0 | 1 |
| 2018 Octubre | 2 | 0 | 2 |
| 2018 Septiembre | 4 | 5 | 9 |
| 2018 Agosto | 0 | 3 | 3 |
| 2018 Julio | 0 | 15 | 15 |
| 2018 Junio | 0 | 4 | 4 |
| 2018 Mayo | 0 | 3 | 3 |
| 2018 Abril | 0 | 3 | 3 |
| 2018 Marzo | 0 | 3 | 3 |
| 2018 Febrero | 30 | 6 | 36 |
| 2018 Enero | 27 | 6 | 33 |
| 2017 Diciembre | 37 | 12 | 49 |
| 2017 Noviembre | 15 | 9 | 24 |
| 2017 Octubre | 25 | 8 | 33 |
| 2017 Septiembre | 25 | 14 | 39 |
| 2017 Agosto | 25 | 13 | 38 |
| 2017 Julio | 20 | 10 | 30 |
| 2017 Junio | 21 | 19 | 40 |
| 2017 Mayo | 22 | 22 | 44 |
| 2017 Abril | 30 | 15 | 45 |
| 2017 Marzo | 14 | 27 | 41 |
| 2017 Febrero | 13 | 23 | 36 |
| 2017 Enero | 19 | 7 | 26 |
| 2016 Diciembre | 25 | 18 | 43 |
| 2016 Noviembre | 27 | 22 | 49 |
| 2016 Octubre | 20 | 22 | 42 |
| 2016 Septiembre | 0 | 10 | 10 |
| 2016 Agosto | 0 | 6 | 6 |
| 2016 Julio | 0 | 2 | 2 |
| 2016 Junio | 2 | 1 | 3 |
| 2016 Mayo | 0 | 1 | 1 |
| 2016 Abril | 0 | 1 | 1 |
| 2016 Marzo | 0 | 3 | 3 |
| 2016 Febrero | 0 | 1 | 1 |
| 2016 Enero | 0 | 1 | 1 |
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