JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
CLINICAL CASE OF THE MONTH
A 44-Year-OldWoman with Rash
H. Martin Plauche, BS, Stephen Lambert, BS, Stratton Grisoli, MD, Skylar Souyoul, MD, Shane Guillory, MD, Fred A. Lopez, MD
In recent years, the immunomodulating agent levamisole has been increasingly used as a cutting agent in cocaine. This contaminant has led to numerous reported cases of levamisole-induced vasculopathy. With the increased use of levamisole-adulterated cocaine, physicians should be aware of the various cutaneous manifestations associatedwith levamisole toxicity.Wedescribe the caseof a chronic cocaineuserwhopresented with extensive hemorrhagic retiform purpura involving the ears, upper extremities, and trunk. Levamisole- induced vasculopathy should always be included in the differential diagnosis of a patient with evidence of vasculitis and history of cocaine abuse. This case emphasizes the importance of timely recognition and proper counseling in order to prevent recurrent episodes of levamisole-induced skin necrosis.
INTRODUCTION
also revealed a microcytic anemia with hemoglobin levels of 10.6 GM/DL (12-16 GM/DL), and a MCV of 74.7 FL (80-100 FL). Inflammatory markers were elevated with a C-reactive protein level of 12.6 MG/DL (<0.90 MG/DL) and an erythrocyte sedimentation rate of 67 MM/HR (0-20 MM/HR ). Blood cultures and HIV tests drawn at admission returned negative. Toxicology screening of the urine was positive for cannabinoids, cocaine, and levamisole. Based on the patient’s recent cocaine use and the characteristic clinical presentation, a presumptive diagnosis of levamisole- induced vasculitis was made. Further immunological workup revealed positive p-ANCA antibodies with a titer of 1:640 (<1:20 titer). C3 complement levels were within normal range, however a low C4 complement of 17 MG/DL (18-55 MG/DL) was present. Additional laboratory tests that were negative included: cryoglobulins, c-ANCA, anticardiolipin panel, rheumatoid factor, antinuclear antibodies, and an extractable nuclear antigen (ENA) panel. Dermatology was consulted, and a punch biopsy of a purpuric lesion on the left forearmwas obtained. Histopathology of the punch biopsy revealed multiple fibrin thrombi distributed throughout the superficial anddeepdermis. Dermal hemorrhage along with perivascular neutrophilic inflammation was also present. Treatment consisted of supportive care and complete withdrawal of cocaine. The patient’s lesions slowly improved, and she was discharged home following counseling on the importance of cocaine cessation.
A 44-year-old woman with a past medical history of untreated, chronic hepatitis C presented to the emergency roomwith acute onset of a widespread rash on her bilateral helices, abdomen, buttocks, and bilateral upper extremities. She was initially seen at an outside hospital one week prior where she was treated with topical permethrin for a presumptive diagnosis of scabies. Subsequently, the tender lesions which had appeared initially on her abdomen and right upper extremity quickly spread to involve the buttocks, posterior thighs, and external ears. She returned to the hospital and was given an additional dose of permethrin cream and tramadol. However, the patient’s cutaneous lesions did not improve and continued to evolve into larger more necrotic plaques. At that point, she presented to our facility. On further evaluation, she admitted to cocaine use on the night prior to onset of her skin findings. She also endorsed history of a similar purpuric eruption that occurred on both lower extremities three years prior after cocaine use. Her vital signs upon presentation included a temperature 98.8 °F, blood pressure 137/79 mmHg, heart rate 112 beats per minute, respiratory rate 18 breaths per minute, and a body mass index of 26.9. Physical examination revealed large, retiform, purpuric plaques with erythematous, inflammatory borders and central hemorrhage and necrosis (Figure 1). Lesions involved the bilateral helices of the ears (Figure 2), bilateral upper arms, forearms, buttocks, and posterior thighs. Multiple faintly hyperpigmented to violaceous macules were scattered over her abdomen and back (Figure 3). The purpuric lesions had a stellate pattern with a notable central necrosis. Laboratory analysis revealed a leukopenia with a WBC count of 3,000 per UL (4,500-11,000 per UL), with an absolute neutrophil count of 1900 per UL (1800-8000 per UL). Laboratory workup
EPIDEMIOLOGY
Drug-induced vasculitis is one of the most common causes of vasculitis inadults. It canbeadiagnosticchallenge todifferentiate between the various idiopathic cutaneous vasculopathies. Illicit
140 J La State Med Soc VOL 169 SEPTEMBER/OCTOBER 2017
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