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Woman With Progressively Worsening Retiform Purpura
IMAGES IN EMERGENCY MEDICINE Nicholls W. Nelson, BS; Brian Hassani, MD; Charles A. Khoury, MD, MSHA 0196-0644/$-see front matter Copyright © 2016 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2016.08.438
Figure 1. Palpable purpura on face.
Figure 2. Retiform purpura on anterior lower extremities.
Figure 3. Purpura with bulla over area of central necrosis on lateral thigh.
[Ann Emerg Med. 2017;69:e13-e14.] A 39-year-old woman presented to the emergency department (ED) after developing a progressively worsening rash during 6 days. The rash consisted of patches of retiform purpura with associated bullae and erythematous borders over her left ear, nose, legs, and hips (Figures 1 through 3). She was initially treated at an outside hospital and prescribed steroids. She then presented to our ED for worsening pain directly over the rash sites. She denied use of any medications. Her lesions did not involve mucous membranes. CBC count, complete metabolic panel, and coagulation study results were unremarkable. She initially denied substance abuse but later admitted to a week-long cocaine binge. For the diagnosis and teaching points, see page e14. To view the entire collection of Images in Emergency Medicine, visit www.annemergmed.com Volume 69, no. 2 : February 2017
Annals of Emergency Medicine e13
Nelson, Hassani & Khoury
Images in Emergency Medicine
IMAGES IN EMERGENCY MEDICINE (continued from p. e13)
DIAGNOSIS: Levamisole-induced leukocytoclastic vasculitis with epidermal necrosis. Presentation with painful retiform purpura opens a broad differential diagnosis, including systemic and vascular coagulopathies, cryoglobulinemia, and platelet plugging disorders.1 Levamisole-induced vasculitis is a diagnosis of exclusion but should be considered in patients with a constellation of palpable purpura or bullae with ear involvement, arthralgias, and leukopenia.2 Suspicion is heightened by history of cocaine use because 71% of cocaine in the United States has been contaminated by levamisole as of 2009.3 The mechanism of action is poorly understood but may involve cocaine-induced vasoconstriction combined with the autoantibody-promoting ability of levamisole.1 Treatment consists of cocaine cessation and supportive care. Antibiotics are not indicated unless there are secondary signs of infection. Steroid use has yielded variable success and should be limited because of the risk of systemic adverse effects and superimposed infection. Patients with extensive necrosis may require debridement and grafting, and amputation has been required in extreme cases.4 Author affiliations: From the Department of Emergency Medicine (Hassani, Khoury), University of Alabama at Birmingham School of Medicine (Nelson), Birmingham, AL. REFERENCES 1. Han C, Sreenivasan G, Dutz JP. Reversible retiform purpura: a sign of cocaine use. CMAJ. 2011;183:E597-E600. 2. Poon SH, Baliog CR Jr, Sams RN, et al. Syndrome of cocaine-levamisole-induced cutaneous vasculitis and immune-mediated leukopenia. Semin Arthritis Rheum. 2011;41:434-444. 3. US Department of Justice. National Drug Threat Drug Assessment 2010. Washington, DC: US Dept of Justice, National Drug Intelligence Center; 2010; Available at: https://www.justice.gov/archive/ndic/pubs38/38661/drugImpact.htm. Accessed August 30, 2016. 4. Arora N, Jain T, Bhanot R, et al. Levamisole-induced leukocytoclastic vasculitis and neutropenia in a patient with cocaine use: an extensive case with necrosis of skin, soft tissue, and cartilage. Addict Sci Clin Pract. 2012;7.1:19.
e14 Annals of Emergency Medicine
Volume 69, no. 2 : February 2017
Figure 1. Palpable purpura on face.
Figure 2. Retiform purpura on anterior lower extremities.
Figure 3. Purpura with bulla over area of central necrosis on lateral thigh.
[Ann Emerg Med. 2017;69:e13-e14.] A 39-year-old woman presented to the emergency department (ED) after developing a progressively worsening rash during 6 days. The rash consisted of patches of retiform purpura with associated bullae and erythematous borders over her left ear, nose, legs, and hips (Figures 1 through 3). She was initially treated at an outside hospital and prescribed steroids. She then presented to our ED for worsening pain directly over the rash sites. She denied use of any medications. Her lesions did not involve mucous membranes. CBC count, complete metabolic panel, and coagulation study results were unremarkable. She initially denied substance abuse but later admitted to a week-long cocaine binge. For the diagnosis and teaching points, see page e14. To view the entire collection of Images in Emergency Medicine, visit www.annemergmed.com Volume 69, no. 2 : February 2017
Annals of Emergency Medicine e13
Nelson, Hassani & Khoury
Images in Emergency Medicine
IMAGES IN EMERGENCY MEDICINE (continued from p. e13)
DIAGNOSIS: Levamisole-induced leukocytoclastic vasculitis with epidermal necrosis. Presentation with painful retiform purpura opens a broad differential diagnosis, including systemic and vascular coagulopathies, cryoglobulinemia, and platelet plugging disorders.1 Levamisole-induced vasculitis is a diagnosis of exclusion but should be considered in patients with a constellation of palpable purpura or bullae with ear involvement, arthralgias, and leukopenia.2 Suspicion is heightened by history of cocaine use because 71% of cocaine in the United States has been contaminated by levamisole as of 2009.3 The mechanism of action is poorly understood but may involve cocaine-induced vasoconstriction combined with the autoantibody-promoting ability of levamisole.1 Treatment consists of cocaine cessation and supportive care. Antibiotics are not indicated unless there are secondary signs of infection. Steroid use has yielded variable success and should be limited because of the risk of systemic adverse effects and superimposed infection. Patients with extensive necrosis may require debridement and grafting, and amputation has been required in extreme cases.4 Author affiliations: From the Department of Emergency Medicine (Hassani, Khoury), University of Alabama at Birmingham School of Medicine (Nelson), Birmingham, AL. REFERENCES 1. Han C, Sreenivasan G, Dutz JP. Reversible retiform purpura: a sign of cocaine use. CMAJ. 2011;183:E597-E600. 2. Poon SH, Baliog CR Jr, Sams RN, et al. Syndrome of cocaine-levamisole-induced cutaneous vasculitis and immune-mediated leukopenia. Semin Arthritis Rheum. 2011;41:434-444. 3. US Department of Justice. National Drug Threat Drug Assessment 2010. Washington, DC: US Dept of Justice, National Drug Intelligence Center; 2010; Available at: https://www.justice.gov/archive/ndic/pubs38/38661/drugImpact.htm. Accessed August 30, 2016. 4. Arora N, Jain T, Bhanot R, et al. Levamisole-induced leukocytoclastic vasculitis and neutropenia in a patient with cocaine use: an extensive case with necrosis of skin, soft tissue, and cartilage. Addict Sci Clin Pract. 2012;7.1:19.
e14 Annals of Emergency Medicine
Volume 69, no. 2 : February 2017