Cocaine-related retiform purpura: evidence to incriminate the adulterant, levamisole
Article first published online: 24 AUG 2010
Copyright © 2010 John Wiley & Sons A/S
Journal of Cutaneous Pathology
Volume 37, Issue 12, pages 1212–1219, December 2010
How to Cite
Walsh, N. M. G., Green, P. J., Burlingame, R. W., Pasternak, S. and Hanly, J. G. (2010), Cocaine-related retiform purpura: evidence to incriminate the adulterant, levamisole. Journal of Cutaneous Pathology, 37: 1212–1219. doi: 10.1111/j.1600-0560.2010.01613.x
- Issue published online: 18 OCT 2010
- Article first published online: 24 AUG 2010
- Accepted for publication July 27, 2010
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.