Cocaine-related retiform purpura: evidence to incriminate the adulterant, levamisole

Authors

  • Noreen M. G. Walsh,

    Corresponding author
    1. Department of Pathology, Capital District Health Authority and Dalhousie University, Halifax, Nova Scotia, Canada
      Dr. Noreen Walsh, Head, Division of Anatomical Pathology, Room 742, D.J. Mackenzie Building, CDHA, QEII Site, 5788 University Avenue, Halifax, Nova Scotia B3H 1V8, Canada
      Tel: +902 473 7706
      Fax: +902 473 7978
      e-mail: noreen.walsh@cdha.nshealth.ca
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  • Peter J. Green,

    1. Department of Medicine, Capital District Health Authority and Dalhousie University, Halifax, Nova Scotia, Canada
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  • Rufus W. Burlingame,

    1. INOVA Diagnostics, Inc., San Diego, CA, USA
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  • Sylvia Pasternak,

    1. Department of Pathology, Capital District Health Authority and Dalhousie University, Halifax, Nova Scotia, Canada
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  • John G. Hanly

    1. Department of Medicine, Capital District Health Authority and Dalhousie University, Halifax, Nova Scotia, Canada
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Dr. Noreen Walsh, Head, Division of Anatomical Pathology, Room 742, D.J. Mackenzie Building, CDHA, QEII Site, 5788 University Avenue, Halifax, Nova Scotia B3H 1V8, Canada
Tel: +902 473 7706
Fax: +902 473 7978
e-mail: noreen.walsh@cdha.nshealth.ca

Abstract

The term ‘cocaine-induced pseudovasculitis' was coined to encompass a constellation of clinical and laboratory findings which mimics a systemic vasculitis but lacks confirmatory evidence of vasculitis on biopsy. Antineutrophil cytoplasmic antibodies reacting with human neutrophil elastase (HNE) have been reported to distinguish the cocaine-related syndrome from a true autoimmune vasculitis. Published cases of retiform purpura related to cocaine use are rare and an etiologic role for levamisole, a common adulterant of cocaine, has been postulated. We describe two female patients aged 39 and 49 years with cocaine-related retiform purpura, mainly affecting the legs. The initial clinical and serological profile in case 1 led to a suspicion of anti-phospholipid syndrome and in case 2 to Wegener's granulomatosis with an unexplained associated neutropenia. Skin biopsies revealed a mixed pattern of leukocytoclastic vasculitis and microvascular thrombosis in case 1 and pure microvascular thrombosis in case 2. Identification of anti-HNE antibodies in both patients linked their disease to cocaine. The mixed vasculopathic pattern in case 1 and the associated neutropenia in case 2, both known adverse effects of levamisole, point to this as the true etiologic agent. Urine toxicology shortly after a binge of cocaine use in each case was positive for levamisole.

Walsh NMG, Green PJ, Burlingame RW, Pasternak S, Hanly JG. Cocaine-related retiform purpura: evidence to incriminate the adulterant, levamisole.

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