Cocaine/levamisole-induced systemic vasculitis with retiform purpura and pauci-immune glomerulonephritis

Levamisole has been increasingly used as an adulterant of cocaine in recent years, emerging as a public health challenge worldwide. Levamisole-associated toxicity manifests clinically as a systemic vasculitis, consisting of cutaneous, hematological, and renal lesions, among others. Purpura retiform,...

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Main Authors: F.V. Veronese, R.S.O. Dode, M. Friderichs, G.G. Thomé, D.R. da Silva, P.G. Schaefer, V.C. Sebben, A.R. Nicolella, E.J.G. Barros
Format: Article
Language:English
Published: Associação Brasileira de Divulgação Científica 2016-01-01
Series:Brazilian Journal of Medical and Biological Research
Subjects:
Online Access:http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0100-879X2016000500501&lng=en&tlng=en
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spelling doaj-282d342cca6c4ff5881e321bf37bc1db2020-11-24T21:55:38ZengAssociação Brasileira de Divulgação CientíficaBrazilian Journal of Medical and Biological Research1414-431X2016-01-0149510.1590/1414-431X20165244S0100-879X2016000500501Cocaine/levamisole-induced systemic vasculitis with retiform purpura and pauci-immune glomerulonephritisF.V. VeroneseR.S.O. DodeM. FriderichsG.G. ThoméD.R. da SilvaP.G. SchaeferV.C. SebbenA.R. NicolellaE.J.G. BarrosLevamisole has been increasingly used as an adulterant of cocaine in recent years, emerging as a public health challenge worldwide. Levamisole-associated toxicity manifests clinically as a systemic vasculitis, consisting of cutaneous, hematological, and renal lesions, among others. Purpura retiform, cutaneous necrosis, intravascular thrombosis, neutropenia, and less commonly crescentic nephritis have been described in association with anti-neutrophil cytoplasmic antibodies (ANCAs) and other autoantibodies. Here we report the case of a 49-year-old male who was a chronic cocaine user, and who presented spontaneous weight loss, arthralgia, and 3 weeks before admission purpuric skin lesions in the earlobes and in the anterior thighs. His laboratory tests on admission showed serum creatinine of 4.56 mg/dL, white blood count 3,800/μL, hemoglobin 7.3 g/dL, urinalysis with 51 white blood cells/μL and 960 red blood cells/μL, and urine protein-to-creatinine ratio 1.20. Serum ANCA testing was positive (>1:320), as well as serum anti-myeloperoxidase and anti-proteinase 3 antibodies. Urine toxicology screen was positive for cocaine and levamisole, with 62.8% of cocaine, 32.2% of levamisole, and 5% of an unidentified substance. Skin and renal biopsies were diagnostic for leukocytoclastic vasculitis and pauci-immune crescentic glomerulonephritis, respectively. The patient showed a good clinical response to cocaine abstinence, and use of corticosteroids and intravenous cyclophosphamide. Last serum creatinine was 1.97 mg/dL, white blood cell count 7,420/μL, and hemoglobin level 10.8 g/dL. In levamisole-induced systemic vasculitis, the early institution of cocaine abstinence, concomitant with the use of immunosuppressive drugs in severe cases, may prevent permanent end organ damage and associate with better clinical outcomes.http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0100-879X2016000500501&lng=en&tlng=enCocaineLevamisoleSystemic vasculitisANCARetiform purpuraCrescentic glomerulonephritis
collection DOAJ
language English
format Article
sources DOAJ
author F.V. Veronese
R.S.O. Dode
M. Friderichs
G.G. Thomé
D.R. da Silva
P.G. Schaefer
V.C. Sebben
A.R. Nicolella
E.J.G. Barros
spellingShingle F.V. Veronese
R.S.O. Dode
M. Friderichs
G.G. Thomé
D.R. da Silva
P.G. Schaefer
V.C. Sebben
A.R. Nicolella
E.J.G. Barros
Cocaine/levamisole-induced systemic vasculitis with retiform purpura and pauci-immune glomerulonephritis
Brazilian Journal of Medical and Biological Research
Cocaine
Levamisole
Systemic vasculitis
ANCA
Retiform purpura
Crescentic glomerulonephritis
author_facet F.V. Veronese
R.S.O. Dode
M. Friderichs
G.G. Thomé
D.R. da Silva
P.G. Schaefer
V.C. Sebben
A.R. Nicolella
E.J.G. Barros
author_sort F.V. Veronese
title Cocaine/levamisole-induced systemic vasculitis with retiform purpura and pauci-immune glomerulonephritis
title_short Cocaine/levamisole-induced systemic vasculitis with retiform purpura and pauci-immune glomerulonephritis
title_full Cocaine/levamisole-induced systemic vasculitis with retiform purpura and pauci-immune glomerulonephritis
title_fullStr Cocaine/levamisole-induced systemic vasculitis with retiform purpura and pauci-immune glomerulonephritis
title_full_unstemmed Cocaine/levamisole-induced systemic vasculitis with retiform purpura and pauci-immune glomerulonephritis
title_sort cocaine/levamisole-induced systemic vasculitis with retiform purpura and pauci-immune glomerulonephritis
publisher Associação Brasileira de Divulgação Científica
series Brazilian Journal of Medical and Biological Research
issn 1414-431X
publishDate 2016-01-01
description Levamisole has been increasingly used as an adulterant of cocaine in recent years, emerging as a public health challenge worldwide. Levamisole-associated toxicity manifests clinically as a systemic vasculitis, consisting of cutaneous, hematological, and renal lesions, among others. Purpura retiform, cutaneous necrosis, intravascular thrombosis, neutropenia, and less commonly crescentic nephritis have been described in association with anti-neutrophil cytoplasmic antibodies (ANCAs) and other autoantibodies. Here we report the case of a 49-year-old male who was a chronic cocaine user, and who presented spontaneous weight loss, arthralgia, and 3 weeks before admission purpuric skin lesions in the earlobes and in the anterior thighs. His laboratory tests on admission showed serum creatinine of 4.56 mg/dL, white blood count 3,800/μL, hemoglobin 7.3 g/dL, urinalysis with 51 white blood cells/μL and 960 red blood cells/μL, and urine protein-to-creatinine ratio 1.20. Serum ANCA testing was positive (>1:320), as well as serum anti-myeloperoxidase and anti-proteinase 3 antibodies. Urine toxicology screen was positive for cocaine and levamisole, with 62.8% of cocaine, 32.2% of levamisole, and 5% of an unidentified substance. Skin and renal biopsies were diagnostic for leukocytoclastic vasculitis and pauci-immune crescentic glomerulonephritis, respectively. The patient showed a good clinical response to cocaine abstinence, and use of corticosteroids and intravenous cyclophosphamide. Last serum creatinine was 1.97 mg/dL, white blood cell count 7,420/μL, and hemoglobin level 10.8 g/dL. In levamisole-induced systemic vasculitis, the early institution of cocaine abstinence, concomitant with the use of immunosuppressive drugs in severe cases, may prevent permanent end organ damage and associate with better clinical outcomes.
topic Cocaine
Levamisole
Systemic vasculitis
ANCA
Retiform purpura
Crescentic glomerulonephritis
url http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0100-879X2016000500501&lng=en&tlng=en
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