Painful purpura associated with exposure to levamisole-adulterated cocaine

Description

A 56-year-old man presented with a 2-day history of a painful rash. Examination revealed necrotic retiform purpura over the trunk and extremities (figure 1). Laboratory testing was notable for leucopenia (3.2 cells/µL) and positive peripheral antineutrophil cytoplasmic antibody (p-ANCA) with antimyeloperoxidase specificity (3.5 U, normal <0.4 U). Skin biopsy showed microvascular thrombosis and fibrinoid necrosis. On questioning, the patient endorsed regular cocaine use.

Figure 1

Necrotic retiform purpura over the trunk and extremities.

The patient was diagnosed with levamisole-induced vasculitis. He was discharged after workup but was readmitted a week later with wound superinfection requiring antibiotic therapy, surgical debridement and skin grafting. He recovered well postoperatively with complete resolution of his wounds at 2-month follow-up.

Levamisole is a veterinary antihelminthic previously used as an immunomodulator and cancer adjuvant prior to its withdrawal in 1999 from US markets due to toxicity. In the early...

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