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Necrotizing Pneumonia in the Setting of Levamisole Vasculitis
Pulmonary Manifestations of Systemic Disease SESSION TITLE: Pulmonary Manifestations of Systemic Disease 4 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM
PULMONARY MANIFESTATIONS OF SYSTEMIC DISEASE
Necrotizing Pneumonia in the Setting of Levamisole Vasculitis Abigail Quintos* Samar Vanaik Abesh Niroula Marisela Rives-Sanchez Karanjit Sandhu and Gokul Samudrala Albert Einstein Medical Center, Philadelphia, PA INTRODUCTION: Although cutaneous necrotizing vasculitis from levamisole-contaminated cocaine is a well-described disease entity, the spectrum of clinical manifestations may be more diverse than what we recognize. CASE PRESENTATION: A 61-year-old male presented with dark discoloration of his ears, nose, fingers and toes. He had a similar presentation a few years back, when cocaine and levamisole were detected in his urine, and he was diagnosed with levamisole-induced vasculitis (LIV). His current symptoms were accompanied by a productive cough with blood-tinged sputum, fevers and chills. He was still using cocaine, and had a distant history of incarceration. Chest x-ray revealed a large right upper lobe opacity. The chest CT scan confirmed the consolidation with cavitation and signs of necrosis. He was initially kept on airborne isolation until three sputum smears were negative for acid-fast bacilli. A bronchoscopy was performed and bronchoalveolar lavage cultures grew Pseudomonas aeruginosa, towards which antibiotics were tailored. Rheumatology and vascular surgery were consulted for the patient’s skin lesions. Serology was positive for perinuclear anti-neutrophilic cytoplasmic antibodies and anti-myeloperoxidase antibodies. He was diagnosed with recurrent LIV in the setting of active cocaine use. Despite a course of prednisone, the patient developed worsening necrotic ulcers, that required emergent amputations of the right leg and left toes. Surgical cultures revealed a polymicrobial growth, and was treated with antibiotics. On three-month follow up, with abstinence from cocaine, the patient had no active vasculitic skin lesions and there was resolution of the cavitary pneumonia on imaging. DISCUSSION: We present a case of necrotizing pneumonia occurring concomitantly with cutaneous lesions in LIV. To our knowledge, there has been only one other case reported with the same presentation. We are uncertain of the association between the two. We hypothesize, however, that in the same process that skin purpura and ulcers occur, an underlying pulmonary necrotizing vasculitis may precede the necrotizing pneumonia. The primary management is to stop exposure to the offending agent. Superimposed infections are treated with antibiotics, as was in our case. CONCLUSIONS: In the future, similar clinical presentations and histopathology may establish this proposed association between levamisole and pulmonary necrotizing vasculitis. Reference #1: Abdul-Karim, R, et al. 2013. “Levamisole-induced vasculitis” Proc (Bayl Univ Med Cent) 26(2):163-165 DISCLOSURE: The following authors have nothing to disclose: Abigail Quintos, Samar Vanaik, Abesh Niroula, Marisela RivesSanchez, Karanjit Sandhu, Gokul Samudrala No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2017.08.969
Copyright ª 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
934A
[
152#4S CHEST OCTOBER 2017
]
PULMONARY MANIFESTATIONS OF SYSTEMIC DISEASE
Necrotizing Pneumonia in the Setting of Levamisole Vasculitis Abigail Quintos* Samar Vanaik Abesh Niroula Marisela Rives-Sanchez Karanjit Sandhu and Gokul Samudrala Albert Einstein Medical Center, Philadelphia, PA INTRODUCTION: Although cutaneous necrotizing vasculitis from levamisole-contaminated cocaine is a well-described disease entity, the spectrum of clinical manifestations may be more diverse than what we recognize. CASE PRESENTATION: A 61-year-old male presented with dark discoloration of his ears, nose, fingers and toes. He had a similar presentation a few years back, when cocaine and levamisole were detected in his urine, and he was diagnosed with levamisole-induced vasculitis (LIV). His current symptoms were accompanied by a productive cough with blood-tinged sputum, fevers and chills. He was still using cocaine, and had a distant history of incarceration. Chest x-ray revealed a large right upper lobe opacity. The chest CT scan confirmed the consolidation with cavitation and signs of necrosis. He was initially kept on airborne isolation until three sputum smears were negative for acid-fast bacilli. A bronchoscopy was performed and bronchoalveolar lavage cultures grew Pseudomonas aeruginosa, towards which antibiotics were tailored. Rheumatology and vascular surgery were consulted for the patient’s skin lesions. Serology was positive for perinuclear anti-neutrophilic cytoplasmic antibodies and anti-myeloperoxidase antibodies. He was diagnosed with recurrent LIV in the setting of active cocaine use. Despite a course of prednisone, the patient developed worsening necrotic ulcers, that required emergent amputations of the right leg and left toes. Surgical cultures revealed a polymicrobial growth, and was treated with antibiotics. On three-month follow up, with abstinence from cocaine, the patient had no active vasculitic skin lesions and there was resolution of the cavitary pneumonia on imaging. DISCUSSION: We present a case of necrotizing pneumonia occurring concomitantly with cutaneous lesions in LIV. To our knowledge, there has been only one other case reported with the same presentation. We are uncertain of the association between the two. We hypothesize, however, that in the same process that skin purpura and ulcers occur, an underlying pulmonary necrotizing vasculitis may precede the necrotizing pneumonia. The primary management is to stop exposure to the offending agent. Superimposed infections are treated with antibiotics, as was in our case. CONCLUSIONS: In the future, similar clinical presentations and histopathology may establish this proposed association between levamisole and pulmonary necrotizing vasculitis. Reference #1: Abdul-Karim, R, et al. 2013. “Levamisole-induced vasculitis” Proc (Bayl Univ Med Cent) 26(2):163-165 DISCLOSURE: The following authors have nothing to disclose: Abigail Quintos, Samar Vanaik, Abesh Niroula, Marisela RivesSanchez, Karanjit Sandhu, Gokul Samudrala No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2017.08.969
Copyright ª 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
934A
[
152#4S CHEST OCTOBER 2017
]