Background Levamisole, an antihelmintic and immunomodulatory agent currently used as a cocaine adulterant; is related with levamisole-induced vasculopathy (LIVEN), characterized by necrosis of ears, retiform purpura, cytopenias and positive anti-neutrophilic cytoplasmic antibody (ANCA)1.
Objectives To describe the clinical features and laboratory findings of 11 patients with LIVEN.
Methods We describe 11 consecutive patients with LIVEN, evaluated at 3 Colombian hospitals from December 2010 to May 2015.
Results Hispanic patients with a median age of 35 years (IR 31–39), 82% were male, had a history of more than 2 years of cocaine abuse, and 1 year of symptoms (IR 10–24). All had necrosis of ears, 91% retiform purpura (limbs, buttocks, face and abdomen), 45% fever, 27% genital necrosis and 9% digital necrosis (image). Skin biopsy (n=9) reported thrombotic vasculopathy (78%), pseudo-vasculitis (33%), and leukocytoclastic vasculitis (33%). Fifty five percent of patients had arthralgia/arthritis, 55% glomerulonephritis, 18% pulmonary disease, serositis or lymphadenopathy, 9% hepatosplenomegaly; 64% chronic disease anemia, 27% leucopenia, 73% lymphopenia, 9% neutropenia, 100% raised acute phase reactants. ANCA were positive in 91%, with perinuclear pattern (IIF) and anti-MPO positive (ELISA) or double positivity (anti-MPO and anti-PR3). Forty five percent exhibit ANA (homogeneous pattern), 29% anti-dsDNA and anti-Ro, 55% hypocomplementemia, 73% lupus anticoagulant, 20% anticardiolipin antibodies and cryoglobulins. Most patients received prednisolone (median dose 50 mg/d, IR 35–60). Lesions resolved in all patients with treatment and cocaine suspension; relapses were associated with resuming consumption.
Conclusions LIVEN cases had increased due to the use of levamisole-adulterated cocaine1. Besides the typical skin lesions, there are hematological, renal, joint and lung manifestations. Main laboratory findings are high ESR and CRP levels, positive ANCA and lupus anticoagulant, although other autoantibodies could be present (aCL, ANA and anti-dsDNA). The differential diagnosis includes systemic vasculitis, systemic lupus erythematosus and antiphospholipid syndrome. The characteristic skin lesions, the relationship with the consumption and the improvement at suspension are diagnostic clues. In this series the clinical and laboratory features were similar to those described in the literature but we found higher renal involvement2. LIVEN should be considered in patients with retiform purpura, ear involvement and multiple autoantibodies posivity.
Roberts JA, Chévez-Barrios P. Levamisole-Induced Vasculitis: A Characteristic Cutaneous Vasculitis Associated With Levamisole-Adulterated Cocaine. Arch Pathol Lab Med 2015;139:1058–61.
Khan TA, Cuchacovich R, Espinoza LR, et al. Hematological, and Immune Abnormalities Associated with Levamisole-Contaminated Cocaine Use. Semin Arthritis Rheum 2011;41:445–54.
Disclosure of Interest None declared
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