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Rash from Levamisole Vasculopathy in a Cocaine Abuser
The Journal of Emergency Medicine, Vol. 45, No. 2, pp. e45–e47, 2013 Copyright Ó 2013 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2013.03.041
Visual Diagnosis in Emergency Medicine RASH FROM LEVAMISOLE VASCULOPATHY IN A COCAINE ABUSER Bradley S. Jackson, MD and Chad M. Cannon, MD, FAAEM Department of Emergency Medicine, University of Kansas Medical Center, Kansas City, Kansas Reprint Address: Chad M. Cannon, MD, FAAEM, Department of Emergency Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mailstop 1045, Kansas City, KS 66160
The patient was counseled extensively on the need to cease use of illicit drugs, and was discharged in stable condition with a plan to follow-up with our rheumatology clinic for laboratory results and further testing. This patient was unfortunately lost to follow-up.
CASE REPORT A 40-year-old woman presented to the Emergency Department for evaluation of nose and bilateral ear rash. The rash had begun approximately 1 week before presentation. She denied medical history or allergies and was taking no medications. She initially denied any recent substance abuse, then later admitted to a history of and continued use of marijuana and cocaine. Physical examination revealed an otherwise healthyappearing female with normal vital signs. The patient had a nontender, stellate, purpuric, macular rash with mild surrounding erythema involving the lobules and helices of both ears (Figures 1–4). A milder form of the same lesion appeared on both sidewalls of the nose superior to the ala (Figure 5). Internal ear examinations were normal, and a focal area of anterior cartilaginous bleeding was noted in right nare. An examination of the rest of her body revealed no other skin abnormalities. Her urine drug screen returned positive for tetrahydrocannabinol and cocaine. A urine specimen was sent for levamisole testing at an outside laboratory and returned positive at a later date with a concentration of 1.8 mg/mL, with 0.10 mg/mL used as the positive reference value. White blood cell and neutrophil counts were within normal ranges. Perinuclear anti-neutrophil cytoplasmic antibody (ANCA) levels returned positive after discharge with titer >1280, cytoplasmic ANCA was negative.
Figure 1. Patient’s left ear, anterolateral view, with purpuric, macular rash.
RECEIVED: 20 September 2012; ACCEPTED: 28 March 2013 e45
e46
B. S. Jackson and C. M. Cannon
Figure 2. Patient’s left ear, posteriolateral view, with purpuric, macular rash.
Figure 4. Patient’s right ear, posteriolateral view, with purpuric, macular rash.
DISCUSSION
agent. Its use has been associated with agranulocytosis, neutropenia, and fever (1). It has also been known to cause cutaneous vasculitis and necrosis, commonly affecting the earlobes (2). ANCAs and antiphospholipid antibodies are frequently detected. Detection of levamisole in the urine can be difficult due to its short half-life of 5– 6 h (3). The cutaneous condition is typically self limiting and resolves when exposure is discontinued (4). Wound care management is generally supportive. Patients with agranulocytosis have been admitted and treated with filgrastim and antibiotics with positive results (1).
Levamisole, an immunomodulator and antihelmith, is suspected to be added to cocaine as a filler and to possibly enhance its euphoric effects. It is now only available in the United States (US) for veterinary use as a deworming
Figure 3. Patient’s right ear, anterolateral view, with purpuric, macular rash.
Figure 5. Patient’s nose, anterior view, with purpuric, macular rash.
Levamisole Vasculopathy
e47
CONCLUSIONS
REFERENCES
Levamisole is increasingly being found in cocaine seized by authorities, with a July 2009 Drug Enforcement Agency report noting 69% of seized cocaine coming into the US testing positive for levamisole as an added agent (5). Recognition of these characteristic skin findings in the Emergency Department will prompt a more focused and efficient workup of the patient, including evaluation for agranulocytosis. This can also save unnecessary testing and consultation, and allow discussion of substance abuse referral in patients who might have originally denied such a history.
1. Zhu NY, Legatt DF, Turner AR. Agranulocytosis after consumption of cocaine adulterated with levamisole. Ann Intern Med 2009;150: 287–9. 2. Gross RL, Brucker J, Bahce-Altuntas A, et al. A novel cutaneous vasculitis syndrome induced by levamisole-contaminated cocaine. Clin Rheumatol 2011;30:1385–92. 3. Kouassi E, Caille G, Lery L, et al. Novel assay and pharmacokinetics of levamisole and p-hydroxylevamisole in human plasma and urine. Biopharm Drug Dispos 1986;7:71–89. 4. Walsh NMG, Green PJ, Burlingame RW, Pasternak S, Hanly JG. Cocaine-related retiform purpura: evidence to incriminate the adulterant, levamisole. J Cutan Pathol 2010;37:1212–9. 5. Centers for Disease Control and Prevention (CDC). Agranulocytosis associated with cocaine use—four States, March 2008 November 2009. MMWR Morb Mortal Wkly Rep 2009;58:1381–5.
http://dx.doi.org/10.1016/j.jemermed.2013.03.041
Visual Diagnosis in Emergency Medicine RASH FROM LEVAMISOLE VASCULOPATHY IN A COCAINE ABUSER Bradley S. Jackson, MD and Chad M. Cannon, MD, FAAEM Department of Emergency Medicine, University of Kansas Medical Center, Kansas City, Kansas Reprint Address: Chad M. Cannon, MD, FAAEM, Department of Emergency Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mailstop 1045, Kansas City, KS 66160
The patient was counseled extensively on the need to cease use of illicit drugs, and was discharged in stable condition with a plan to follow-up with our rheumatology clinic for laboratory results and further testing. This patient was unfortunately lost to follow-up.
CASE REPORT A 40-year-old woman presented to the Emergency Department for evaluation of nose and bilateral ear rash. The rash had begun approximately 1 week before presentation. She denied medical history or allergies and was taking no medications. She initially denied any recent substance abuse, then later admitted to a history of and continued use of marijuana and cocaine. Physical examination revealed an otherwise healthyappearing female with normal vital signs. The patient had a nontender, stellate, purpuric, macular rash with mild surrounding erythema involving the lobules and helices of both ears (Figures 1–4). A milder form of the same lesion appeared on both sidewalls of the nose superior to the ala (Figure 5). Internal ear examinations were normal, and a focal area of anterior cartilaginous bleeding was noted in right nare. An examination of the rest of her body revealed no other skin abnormalities. Her urine drug screen returned positive for tetrahydrocannabinol and cocaine. A urine specimen was sent for levamisole testing at an outside laboratory and returned positive at a later date with a concentration of 1.8 mg/mL, with 0.10 mg/mL used as the positive reference value. White blood cell and neutrophil counts were within normal ranges. Perinuclear anti-neutrophil cytoplasmic antibody (ANCA) levels returned positive after discharge with titer >1280, cytoplasmic ANCA was negative.
Figure 1. Patient’s left ear, anterolateral view, with purpuric, macular rash.
RECEIVED: 20 September 2012; ACCEPTED: 28 March 2013 e45
e46
B. S. Jackson and C. M. Cannon
Figure 2. Patient’s left ear, posteriolateral view, with purpuric, macular rash.
Figure 4. Patient’s right ear, posteriolateral view, with purpuric, macular rash.
DISCUSSION
agent. Its use has been associated with agranulocytosis, neutropenia, and fever (1). It has also been known to cause cutaneous vasculitis and necrosis, commonly affecting the earlobes (2). ANCAs and antiphospholipid antibodies are frequently detected. Detection of levamisole in the urine can be difficult due to its short half-life of 5– 6 h (3). The cutaneous condition is typically self limiting and resolves when exposure is discontinued (4). Wound care management is generally supportive. Patients with agranulocytosis have been admitted and treated with filgrastim and antibiotics with positive results (1).
Levamisole, an immunomodulator and antihelmith, is suspected to be added to cocaine as a filler and to possibly enhance its euphoric effects. It is now only available in the United States (US) for veterinary use as a deworming
Figure 3. Patient’s right ear, anterolateral view, with purpuric, macular rash.
Figure 5. Patient’s nose, anterior view, with purpuric, macular rash.
Levamisole Vasculopathy
e47
CONCLUSIONS
REFERENCES
Levamisole is increasingly being found in cocaine seized by authorities, with a July 2009 Drug Enforcement Agency report noting 69% of seized cocaine coming into the US testing positive for levamisole as an added agent (5). Recognition of these characteristic skin findings in the Emergency Department will prompt a more focused and efficient workup of the patient, including evaluation for agranulocytosis. This can also save unnecessary testing and consultation, and allow discussion of substance abuse referral in patients who might have originally denied such a history.
1. Zhu NY, Legatt DF, Turner AR. Agranulocytosis after consumption of cocaine adulterated with levamisole. Ann Intern Med 2009;150: 287–9. 2. Gross RL, Brucker J, Bahce-Altuntas A, et al. A novel cutaneous vasculitis syndrome induced by levamisole-contaminated cocaine. Clin Rheumatol 2011;30:1385–92. 3. Kouassi E, Caille G, Lery L, et al. Novel assay and pharmacokinetics of levamisole and p-hydroxylevamisole in human plasma and urine. Biopharm Drug Dispos 1986;7:71–89. 4. Walsh NMG, Green PJ, Burlingame RW, Pasternak S, Hanly JG. Cocaine-related retiform purpura: evidence to incriminate the adulterant, levamisole. J Cutan Pathol 2010;37:1212–9. 5. Centers for Disease Control and Prevention (CDC). Agranulocytosis associated with cocaine use—four States, March 2008 November 2009. MMWR Morb Mortal Wkly Rep 2009;58:1381–5.