Levamisole induced vasculopathy

Levamisole

  • Initially marketed as antihelminthixc drug and immunomodulator. Was used to treat cancers, and different autoimmune diseases.
  • Was withdrawn from market in 1999 due to side effects (agranulocytosis and vasculitis).

Levamisole as an adulterant in cocaine

  • Metabolite of levamisole can inhibit NE reuptake, therefore prolonging cocaine effect.

Levamisole induced vasculopathy

  • Pathognomonic lesion is purpura bilaterally at the ears (helices), but can spread to facial areas (eg cheeks) or involve upper/lower extremities.
    – Not many involve ears. Possibly because ears have lower temperature that immune deposits may settle there.
  • Have a latency period for up to 5 years
  • As levamisole can lead to agaranulocytosis, a CBC screen can also help in diagnosis.

Diagnosis

  • Basically clinical
  • Interesting auto-antibodies: ANCA antibodies can be found in levamisole-induced vasculopathy
    – pANCA can be found in 100% of the patients, cANCA in 50% of the patients.
    – mean latency of 24 months for development of these antibodies
  • The histopathologic findings of cocaine-levamisole cutaneous vasculopathy syndrome range from leukocytoclastic and thrombotic vasculitis to vascular occlusive disease without true vasculitis

Treatment

  • Treatment with topical steroids is controversial.
  • The most important is DISCONTINUATION of cocaine. The lesion will resolve in weeks.
  • In severe cases, may need abx cover for suspected superinfection (before the culture results come back)
    – Debridement with skin grafting maybe needed in more extensive lesions.

References:

  1. Huy Tran, MD, PhD,* Debbie Tan, MD,* and Thomas P. Marnejon, DO. Cutaneous Vasculopathy Associated with Levamisole-Adulterated Cocaine. Clin Med Res. 2013 Feb; 11(1): 26–30
  2. Raghad Abdul-Karim, MD,corresponding author Caitriona Ryan, MD, Christina Rangel, and Michael Emmett, MD. Levamisole-induced vasculitis. Proc (Bayl Univ Med Cent). 2013 Apr; 26(2): 163–165
  3. Mark B. Ellis, DPM, and William D. Fishco, DPM, FACFAS. Treating Vasculitis Arising From Levamisole-Contaminated Cocaine. Podiatry Today, Aug 2014; 27(8)
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