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C-reactive protein &#40;CRP&#41; of 313&#44; and a glomerular filtration rate of 9&#160;mL&#47;min&#46; Antineutrophil cytoplasmic antibodies &#40;ANCAs&#41; and lupus anticoagulant were positive&#44; whereas cryoglobulins were negative&#46; A chest x-ray showed bilateral disperse alveolar-interstitial infiltrates and the patient was therefore diagnosed with lobar pneumonia and acute kidney failure&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">A punch biopsy of one of the skin lesions was performed and revealed massive occupation of the capillaries by mixed thrombi&#44; with some trapped polymorphonuclear cells&#44; without the characteristic abnormalities of leukocytoclastic vasculitis &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a>&#41;&#46; The differential diagnosis included thrombotic thrombocytopenic purpura&#44; disseminated intravascular coagulation&#44; cryoglobulinemia&#44; and retiform purpura associated with cocaine use&#46; The first 2 entities were ruled out clinically and the third was ruled out due to the absence of cryoglobulins&#46; The patient subsequently admitted to using cocaine&#46; The skin lesions remitted after administering treatment with methylprednisolone and the patient was referred to a mental-health center for cessation of cocaine use&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Levamisole is an anthelminthic drug that&#44; due to its immunomodulatory effect&#44; was used in the past to treat rheumatoid arthritis&#44; collagenopathies&#44; inflammatory bowel disease&#44; pediatric nephrotic syndrome&#44; and cancer&#46; In 2000&#44; the US Food and Drug Administration &#40;FDA&#41; withdrew the drug from the market due to its severe adverse effects&#44; such as vasculitis and blood disorders &#40;especially agranulocytosis&#41;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a>&#59; the drug was&#44; however&#44; maintained for veterinary use&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">It has gained notoriety since 2008 through its use as an adulterant for cocaine due to its similar consistency&#44; its availability&#44; and its synergic activity&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> A syndrome has therefore been described in users of this drug that is characterized by retiform purpura&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> pauci-immune crescentic glomerulonephritis&#44; pulmonary hemorrhage with vasculitis&#44; pulmonary hypertension&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5</span></a> and arthritis deformans&#44; with variable frequency&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Serology reveals higher titers of perinuclear antineutrophilic antibodies than in idiopathic vasculitis&#46; Its association with antinuclear antibodies &#40;ANAs&#41;&#44; anti-double stranded DNA &#40;anti-dsDNA&#41;&#44; and antiphospholipids such as lupus anticoagulant and anticardiolipin has also been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> A study carried out in Spain in 2009 determined that 48&#37; of cocaine samples studied contained levamisole&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The most notable symptom&#44; and the one that causes patients to seek consultation&#44; is the cutaneous symptom&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It has also been found that 60&#37; of these patients have blood disorders and between 95&#37; and 100&#37; have high ANCA titers&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It usually manifests as retiform purpura involving the outer ear&#44; zygomatic arches&#44; and extremities&#44; while sparing the torso&#46; Typical histopathology findings include small-vessel leukocytoclastic vasculitis with fibrinoid necrosis of the vascular wall&#44; extravasation of erythrocytes&#44; karyorrhexis and angiocentric inflammation&#44; and multiple fibrin thrombi in the vessels of the superficial and deep dermis&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3&#44;5</span></a> These findings may present together or separately&#59; microvascular thrombosis is the most consistent of these findings<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and was the only one found in our case&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Cascio and Jen<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> have suggested naming this constellation of abnormalities cocaine&#47;levamisole-associated autoimmune syndrome &#40;CLAAS&#41;&#46; As well as the retiform purpura with the characteristic pattern&#44; our patient presented a thrombotic vasculopathy&#44; thrombocytopenia&#44; neutropenia&#44; lupus anticoagulant&#44; and ANAs&#46; Although the patient presented acute kidney failure&#44; there is no clinical confirmation that this was due to the use of cocaine and levamisole&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The diagnosis of CLAAS is by exclusion&#46; It should be considered in all patients with a history of cocaine use who present with purpura of the characteristics described above&#44; joint pain&#44; neutropenia&#44; and high ANCA titers<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> in the absence of other apparent etiologies&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The basis of treatment is ceasing cocaine&#44; and thus levamisole&#44; use&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;5</span></a> The literature shows treatment data similar to those for primary vasculitis&#58; immunosuppression&#44; anticoagulation&#44; and antiaggregation&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In our patient&#44; the dermal lesions remitted after treatment with methylprednisolone&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">This study has not received funding of any kind&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of Interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Case and Research Letters
Cocaine/Levamisole-Associated Autoimmune Syndrome: A Case Report
Síndrome autoinmune cocaína-levamisol. Presentación de un caso
M.I. Cevallos Abada,
Autor para correspondencia
mcevalla@navarra.es

Corresponding author.
, A. Córdoba Iturriagagoitiaa, M. Larrea Garcíab
a Servicio de Anatomía Patológica, Complejo Hospitalario de Navarra, Navarra, Spain
b Servicio de Dermatología, Complejo Hospitalario de Navarra, Navarra, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 55-year-old man visited the emergency department with clinical signs and symptoms that had appeared some days earlier&#44; consisting of progressive dyspnea accompanied by fever of up to 39&#160;&#176;<span class="elsevierStyleSmallCaps">C</span>&#44; productive cough&#44; and flat&#44; red-violaceous reticulated lesions with a purplish appearance on the left outer ear &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; left malar region&#44; right nostril&#44; and both arms&#46; The patient was an ex-intravenous drug abuser and had a history of stage-2 infection with the human immunodeficiency virus &#40;HIV&#41;&#44; hepatitis B virus&#44; hepatitis C virus&#44; which was cured spontaneously&#44; and presented chronic neutropenia&#46; Laboratory tests showed leukopenia and thrombocytopenia&#44; creatinine levels of 6&#160;mg&#47;dL&#44; procalcitonin of 3&#46;74&#44; C-reactive protein &#40;CRP&#41; of 313&#44; and a glomerular filtration rate of 9&#160;mL&#47;min&#46; Antineutrophil cytoplasmic antibodies &#40;ANCAs&#41; and lupus anticoagulant were positive&#44; whereas cryoglobulins were negative&#46; A chest x-ray showed bilateral disperse alveolar-interstitial infiltrates and the patient was therefore diagnosed with lobar pneumonia and acute kidney failure&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">A punch biopsy of one of the skin lesions was performed and revealed massive occupation of the capillaries by mixed thrombi&#44; with some trapped polymorphonuclear cells&#44; without the characteristic abnormalities of leukocytoclastic vasculitis &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a>&#41;&#46; The differential diagnosis included thrombotic thrombocytopenic purpura&#44; disseminated intravascular coagulation&#44; cryoglobulinemia&#44; and retiform purpura associated with cocaine use&#46; The first 2 entities were ruled out clinically and the third was ruled out due to the absence of cryoglobulins&#46; The patient subsequently admitted to using cocaine&#46; The skin lesions remitted after administering treatment with methylprednisolone and the patient was referred to a mental-health center for cessation of cocaine use&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Levamisole is an anthelminthic drug that&#44; due to its immunomodulatory effect&#44; was used in the past to treat rheumatoid arthritis&#44; collagenopathies&#44; inflammatory bowel disease&#44; pediatric nephrotic syndrome&#44; and cancer&#46; In 2000&#44; the US Food and Drug Administration &#40;FDA&#41; withdrew the drug from the market due to its severe adverse effects&#44; such as vasculitis and blood disorders &#40;especially agranulocytosis&#41;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a>&#59; the drug was&#44; however&#44; maintained for veterinary use&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">It has gained notoriety since 2008 through its use as an adulterant for cocaine due to its similar consistency&#44; its availability&#44; and its synergic activity&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> A syndrome has therefore been described in users of this drug that is characterized by retiform purpura&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> pauci-immune crescentic glomerulonephritis&#44; pulmonary hemorrhage with vasculitis&#44; pulmonary hypertension&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5</span></a> and arthritis deformans&#44; with variable frequency&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Serology reveals higher titers of perinuclear antineutrophilic antibodies than in idiopathic vasculitis&#46; Its association with antinuclear antibodies &#40;ANAs&#41;&#44; anti-double stranded DNA &#40;anti-dsDNA&#41;&#44; and antiphospholipids such as lupus anticoagulant and anticardiolipin has also been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> A study carried out in Spain in 2009 determined that 48&#37; of cocaine samples studied contained levamisole&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The most notable symptom&#44; and the one that causes patients to seek consultation&#44; is the cutaneous symptom&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It has also been found that 60&#37; of these patients have blood disorders and between 95&#37; and 100&#37; have high ANCA titers&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It usually manifests as retiform purpura involving the outer ear&#44; zygomatic arches&#44; and extremities&#44; while sparing the torso&#46; Typical histopathology findings include small-vessel leukocytoclastic vasculitis with fibrinoid necrosis of the vascular wall&#44; extravasation of erythrocytes&#44; karyorrhexis and angiocentric inflammation&#44; and multiple fibrin thrombi in the vessels of the superficial and deep dermis&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3&#44;5</span></a> These findings may present together or separately&#59; microvascular thrombosis is the most consistent of these findings<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and was the only one found in our case&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Cascio and Jen<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> have suggested naming this constellation of abnormalities cocaine&#47;levamisole-associated autoimmune syndrome &#40;CLAAS&#41;&#46; As well as the retiform purpura with the characteristic pattern&#44; our patient presented a thrombotic vasculopathy&#44; thrombocytopenia&#44; neutropenia&#44; lupus anticoagulant&#44; and ANAs&#46; Although the patient presented acute kidney failure&#44; there is no clinical confirmation that this was due to the use of cocaine and levamisole&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The diagnosis of CLAAS is by exclusion&#46; It should be considered in all patients with a history of cocaine use who present with purpura of the characteristics described above&#44; joint pain&#44; neutropenia&#44; and high ANCA titers<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> in the absence of other apparent etiologies&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The basis of treatment is ceasing cocaine&#44; and thus levamisole&#44; use&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;5</span></a> The literature shows treatment data similar to those for primary vasculitis&#58; immunosuppression&#44; anticoagulation&#44; and antiaggregation&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In our patient&#44; the dermal lesions remitted after treatment with methylprednisolone&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">This study has not received funding of any kind&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of Interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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ISSN: 15782190
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