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LEVAMISOLE INDUCED VASCULITIS IN A COCAINE USER Joseph Blatt MD

LEVAMISOLE INDUCED VASCULITIS IN A COCAINE USER Joseph Blatt MD Medical University of South Carolina, Charleston, South Carolina. LEVAMISOLE. LEARNING OBJECTIVES. An imidizothiazole previously used for antihelmin and immunomodulatory effects

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LEVAMISOLE INDUCED VASCULITIS IN A COCAINE USER Joseph Blatt MD

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  1. LEVAMISOLE INDUCED VASCULITIS IN A COCAINE USER Joseph Blatt MD Medical University of South Carolina, Charleston, South Carolina LEVAMISOLE LEARNING OBJECTIVES • An imidizothiazole previously used for antihelmin and immunomodulatory effects • Withdrawn from US market in 2000 for side effects of vasculitis and agranulocytosis • In 2000 became recognized as a cocaine adulterant – undetectable on street market and may enhance euphoric effects of cocaine • CDC reports 70% of US supply of cocaine my be adulterated with levamisole • Recognize levamisole is an increasingly common cocaine adulterant with serious health consequences. • Suspect exposure to levamisole in patients presenting with unexplained neutropenia, necrotic skin lesions, and a history of cocaine use. CASE PRESENTATION • 40 yo WF with admitted for rash beginning on the legs with progression to the ears, abdomen, chest, bilateral elbows, scalp • PE:retiformpurpura in various stages of abscess formation and central necrosis • PMH: frequent cocaine use, Hep C • LABS: UDS cocaine+, p-ANCA>1:1280, MPO positive, RF 24, urine levamisole • BIOPSY:Leukocytoclasticvasculitis with thrombotic vasculopathy • HOSPITAL COURSE : • Patient counseled on importance of cessation of cocaine use • IV steroids for positive p-ANCA • Vancomycin for superimposed MRSA infection CONCLUSIONS Figure 1.Retiformpurpura of LevamisoleVasculitis . • With >2 million Americans using cocaine, occurrences of levamisole induced vasculitis will increase. • Levamisoleexposure should be included in the differential of patients with purpuricvasculitis,neutropenia, and cocaine use. LEVAMISOLE INDUCED VASCULOPATHY • Painful retiformpurpura with evolution to necrosis • Agranulocytosis, neutropenia • Autoantibodies: MPO, p-ANCA>c-ANCA, human neutrophilelastase, ACL, PR3 • Urine levamisole: half-life 5.6 hours • Cocaine use • Purpuratypically present on nose and ears • Primary treatment is cessation of cocaine • Ulcers may require debridement, • Monitor for superinfection REFERENCES • Centers for Disease Control and Prevention (CDC). Agranulocytosis associated with cocaine use – four states, March 2008-November 2009. MMWR Morb Mortal Wkly Rep 2009:58;1381-1385. • Buchanan JA. A confirmed case of agranulocytosis after use of cocaine contaminated with levamisole. J Med Toxicol 2010:6;160-164. • Lauren Geller MD1. Retiformpurpura: A new stigmata of illicit drug use? Dermatology Online Journal 17 (2): 7. • Tahir A. KhanMD. Vasculopathy, Hematological, and Immune Abnormalities Associated with Levamisole-Contaminated Cocaine Use.SeminArthritits Rheum 2011: 41:445-454. • Waller JM. Cocaine-associated retiformpurpura and neutropenia: Is levamisole the culprit? J Am AcadDermatol 2010;63:530-535. • Special Thanks: Vivianne Beyer MD, Cynthia Wilson MD, Ross Pollack MD, Julie Swick MD, Paul Anderson MD, Keri Holmes-Maybank MD

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