Levamisole-Induced Vasculopathy and Associated Skin Necrosis in Crack/Cocaine Users.
Katarina Pavenski, Hilde Vandenberghe, Henry Jakubovic, David Adam, Bernadette Garvey, Catherine J Streutker. St. Michael's Hospital and the University of Toronto, ON, Cape Verde; St. Michael's Hospital and the University of Toronto, ON, Canada
Background: Levamisole had been used as an anti-helminthic as well as an immunomodulatory drug before being taken off the market in 2003. In therapeutic settings, levamisole use has been linked to agranulocytosis and skin necrosis. Starting in 2004, this drug has been reported in a high proportion of seized cocaine in North America and Europe. Cases of febrile neutropenia were observed in users of crack/cocaine contaminated with levamisole. Cases of skin necrosis in this setting have recently been reported in lay literature. Levamisole induced skin necrosis, when observed in therapeutic setting, improves gradually after discontinuation of medication and in some cases, immunosuppression.
Design: Three patients presented to St. Michael's Hospital with history and/or laboratory evidence of crack/cocaine usage and development of skin lesions.
Results: All three patients were young Caucasian females who presented over a period of three months with rapidly progressive painful necrotic skin lesions. The lesions were predominantly located on cheeks, ears, breasts, and buttocks. Extremities were involved in two patients and upper respiratory tract mucosa in one. Skin biopsy in all cases revealed thrombotic vasculopathy with foci of vasculitis in a non-specific pattern, with overlying ischemic ulceration of skin and soft tissues. The first patient was given a provisional diagnosis of cryoglobulinemic vasculitis and treated with plasmapheresis, which resulted in rapid improvement in her skin lesions. Two relapses were successfully treated with plasmapheresis and steroids. Considering the first patient's prompt response to plasmapheresis, the subsequent two patients were offered plasmapheresis as well and had improvement or stabilization of the skin lesions.
Conclusions: Levamisole is frequently added to crack/cocaine to augment the effect; we report three female patient who developed vascular thrombosis and skin necrosis after using levamisole-contaminated crack/cocaine.
Wednesday, March 2, 2011 1:00 PM
Poster Session VI # 132, Wednesday Afternoon