Cocaine-related retiform purpura: evidence to incriminate the adulterant, levamisole.

Publisher: Wiley Country of Publication: United States NLM ID: 0425124 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1600-0560 (Electronic) Linking ISSN: 03036987 NLM ISO Abbreviation: J Cutan Pathol Subsets: MEDLINE

Publication: Malden, MA : Wiley
Original Publication: Copenhagen, Blackwell Munksgaard.

Cocaine-Related Disorders*; Antirheumatic Agents/*adverse effects ; Cocaine/*adverse effects ; Drug Hypersensitivity/*pathology ; Levamisole/*adverse effects ; Purpura/*pathology ; Vasculitis/*pathology; Adult ; Antibodies, Antineutrophil Cytoplasmic/blood ; Antiphospholipid Syndrome/blood ; Antiphospholipid Syndrome/chemically induced ; Antiphospholipid Syndrome/pathology ; Antirheumatic Agents/administration & dosage ; Biopsy ; Cocaine/administration & dosage ; Diagnosis, Differential ; Drug Hypersensitivity/blood ; Female ; Granulomatosis with Polyangiitis/blood ; Granulomatosis with Polyangiitis/chemically induced ; Granulomatosis with Polyangiitis/pathology ; Humans ; Levamisole/administration & dosage ; Middle Aged ; Purpura/blood ; Purpura/chemically induced ; Vasculitis/blood ; Vasculitis/chemically induced

The term 'cocaine-induced pseudovasculitis' was coined to encompass a constellation of clinical and laboratory findings which mimics a systemic vasculitis but lacks confirmatory evidence of vasculitis on biopsy. Antineutrophil cytoplasmic antibodies reacting with human neutrophil elastase (HNE) have been reported to distinguish the cocaine-related syndrome from a true autoimmune vasculitis. Published cases of retiform purpura related to cocaine use are rare and an etiologic role for levamisole, a common adulterant of cocaine, has been postulated. We describe two female patients aged 39 and 49 years with cocaine-related retiform purpura, mainly affecting the legs. The initial clinical and serological profile in case 1 led to a suspicion of anti-phospholipid syndrome and in case 2 to Wegener's granulomatosis with an unexplained associated neutropenia. Skin biopsies revealed a mixed pattern of leukocytoclastic vasculitis and microvascular thrombosis in case 1 and pure microvascular thrombosis in case 2. Identification of anti-HNE antibodies in both patients linked their disease to cocaine. The mixed vasculopathic pattern in case 1 and the associated neutropenia in case 2, both known adverse effects of levamisole, point to this as the true etiologic agent. Urine toxicology shortly after a binge of cocaine use in each case was positive for levamisole.
(Copyright © 2010 John Wiley & Sons A/S.)

0 (Antibodies, Antineutrophil Cytoplasmic)
0 (Antirheumatic Agents)
2880D3468G (Levamisole)
I5Y540LHVR (Cocaine)

Date Created: 20100827 Date Completed: 20110128 Latest Revision: 20220309

20221213

10.1111/j.1600-0560.2010.01613.x

20738457