ANCA-positive necrotizing vasculitis and thrombotic vasculopathy induced by levamisole-adulterated cocaine: A distinctive clinicopathologic presentation

Treatment of cutaneous sarcoidosis using topical photodynamic therapy with minimal discomfort using a fractionated dosing regime and the role of thalidomide and other agents is described.

Abstract

To the Editor: More than 70% of the cocaine supply in the United States is contaminated with levamisole. 1 Centers for Disease Control and Prevention (CDC)Agranulocytosis associated with cocaine use - four states, March 2008-November 2009. MMWR Morb Mortal Wkly Rep. 2009; 58: 1381-1385 PubMed Google Scholar Used previously to treat colon cancer, rheumatoid arthritis, and pediatric nephrotic syndrome, levamisole has been withdrawn in the U.S.; it is being used worldwide to adulterate cocaine, perhaps because it potentiates cocaine effects through a dopaminergic mechanism. Systemic levamisole has been associated with anti-neutrophil cytoplasmic antibody (ANCA)–positive cutaneous vasculitis affecting ears and cheeks and showing histopathology of occlusive vasculopathy with or without leukocytoclastic vasculitis (LCV). 2 Rongioletti F. Ghio L. Ginevri F. Bleidl D. Rinaldi S. Edefonti A. et al. Purpura of the ears: a distinctive vasculopathy with circulating autoantibodies complicating long-term treatment with levamisole in children. Br J Dermatol. 1999; 140: 948-951 Crossref PubMed Scopus (126) Google Scholar Vasculitis secondary to snorting levamisole-adulterated cocaine has been only recently suspected 3 Bradford M. Rosenberg B. Moreno J. Dumyati G. Bilateral necrosis of earlobes and cheeks: another complication of cocaine contaminated with levamisole. Ann Intern Med. 2010; 152: 758-759 Crossref PubMed Scopus (89) Google Scholar , 4 Waller J.M. Feramisco J.D. Alberta-Wszolek L. McCalmont T.H. Fox L.P. Cocaine-associated retiform purpura and neutropenia: is levamisole the culprit?. J Am Acad Dermatol. 2010; 63 (Epub 2010 Mar 20): 530-535 Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar ; the authors presumed retrospectively levamisole contamination and questioned whether retiform purpura of ears and cheeks may be a feature of levamisole adulteration of cocaine. 4 Waller J.M. Feramisco J.D. Alberta-Wszolek L. McCalmont T.H. Fox L.P. Cocaine-associated retiform purpura and neutropenia: is levamisole the culprit?. J Am Acad Dermatol. 2010; 63 (Epub 2010 Mar 20): 530-535 Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar