JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
anti-cardiolipin, and anti-double-stranded DNA antibodies. 12 Of note, a number of other drugs including propylthiouracil, hydralazine, and minocycline have also been associated with ANCA-associated vasculitis. 13 Other common laboratory findings of LIV include agranulocytosis and neutropenia. Histopathologic evaluation of skin biopsy in LIV typically reveals a leukocytoclastic vasculitis of the small vessels as well as vasculopathic features including intravascular thrombi. 14 There is a predominantly neutrophilic inflammatory infiltrate that invades the vessel walls spreading into the perivascular area. A high number of eosinophils is also a common finding. Fibrinoid necrosis along with the extravasation of red blood cells is frequently seen as well. 9
14. Nolan AL and Jen KY. Pathologic manifestations of levamisole-adulterated cocaine exposure. Diagn Pathol 2015; 10:48. 15. Pearson T, Bremmer M, Cohen J, et al. Vasculopathy related to cocaine adulterated with levamisole: A review of the literature. Dermatol Online J 2012; 18(7):1.
H. Plauche and S. Lambert are both fourth-year medical students at Louisiana State University Health Sciences Center School of Medicine in New Orleans. Dr. Grisoli is a second-year Resident in Dermatology in the Department of Dermatology at LSUHSC-New Orleans. Dr. Souyoul is a third-year Resident in Dermatology in the Department of Dermatology at LSUHSC-New Orleans, Louisiana. Dr. Guillory is an Assistant Professor in the Department of Medicine at LSUHSC-New Orleans. Dr. Lopez is the Richard Vial Professor and Vice Chair for Education in the Department of Medicine at LSUHSC-NewOrleans, Louisiana.
MANAGEMENT
Treatment of levamisole-induced cutaneous vasculitis requires supportive care and counseling on cocaine cessation which, in most cases, leads to resolution of symptoms. There is no strong evidence that steroids are needed for the treatment of LIV cutaneous lesions. 15 Steroid use should be withheld due to the possibility of infections in patients who are neutropenic. Patients must be educated on the recurrence of the necrotizing lesions if cocaine use is resumed. In some patients, extensive tissue involvement can lead to amputation and severe infection. 5
REFERENCES
1. National Institute on Drug Abuse. Nationwide Trends. <https://www. drugabuse.gov/publications/drugfacts/nationwide-trends> (accessed May 21, 2016). 2. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings. <http://www.samhsa.gov/data/sites/default/files/ NSDUHresults2012/NSDUHresults2012.pdf. 2012> (accessed May 21, 2016). 3. Amery WK and Bruynseels JP. Levamisole, the story and the lessons. Int J Immunopharmacol 1992; 14(3): 481-486. 4. Macfarlane DG and Bacon PA. Levamisole-induced vasculitis due to circulating immune complexes. Br Med J 1978; 1(6110): 407-408. 5. Centers for Disease Control and Prevention. Agranulocytosis associated with cocaine use - four States, March 2008-November 2009. MMWR Morb Mortal Wkly Rep 2009; 58(49):1381-1385. 6. Symoens J, Veys E, Mielants M, Pinals R. Adverse reactions to levamisole. Cancer Treat Rep 1978; 62(11): 1721-1730. 7. Chang A, Osterloh J, Thomas J. Levamisole: a dangerous new cocaine adulterant. Clin Pharmacol Ther 2010; 88(3):408-411. 8. Bradford M, Rosenberg B, Moreno J, Dumyati G. Bilateral necrosis of earlobes and cheeks: another complication of cocaine contaminated with levamisole. Ann Intern Med. 2010; 152(11):758-759. 9. Czuchlewski DR, Brackney M, Ewers C, et al. Clinicopathologic features of agranulocytosis in the setting of levamisole-tainted cocaine. Am J Clin Pathol 2010; 133(3):466-472. 10. Rongioletti F, Ghio L, Ginevri F, et al. Purpura of the ears: a distinctive vasculopathy with circulating autoantibodies complicating long-term treatment with levamisole in children. Br J Dermatol 1999; 140(5):948-951. 11. Arora, NP. Cutaneous vasculopathy and neutropenia associated with levamisole-adulterated cocaine. Am J Med Sci 2013; 345(1):45-51. 12. Graf J, LynchK,YehCL, et al. Purpura, cutaneous necrosis, and antineutrophil cytoplasmic antibodies associated with levamisole-adulterated cocaine. Arthritis Rheum 2011; 63(12):3998-4001. 13. Gao Y, Zhao MH. Drug-Induced anti-neutrophilic cytoplasmic anti-body associated vasculitis. Nephrology 2009; 14:33–41.
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