SHM Converge Scientific Abstract ePoster Gallery-Peripheral Neuropathy: A Unique Presentation of Levamisole-Induced Vasculitis

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This case describes a 67-year-old woman with six weeks of progressive bilateral upper- and lower-extremity weakness, burning pain, and difficulty walking. Her exam showed a stocking-glove neuropathy, and initial evaluation for common causes was unrevealing. Because she also had leukocytosis, elevated ESR/CRP, low-grade fevers, and spinal MRI abnormalities, clinicians initially suspected infection such as osteomyelitis or spinal abscess. However, the neurologic exam was not consistent with a spinal source, so a peripheral neuropathy and autoimmune workup was pursued.<br /><br />During hospitalization and readmission, diagnostic momentum biased the team toward infection, especially after an incomplete earlier workup and premature discharge. With worsening symptoms and acute kidney injury, renal biopsy revealed focal necrotizing and diffuse crescentic pauci-immune glomerulonephritis, along with necrotizing leukocytoclastic vasculitis. Serologies were atypical for classic MPO vasculitis, but the patient’s social history revealed cocaine use, raising concern for levamisole-adulterated cocaine–induced vasculitis.<br /><br />Levamisole is a cocaine cutting agent known to cause autoimmune and vasculitic syndromes, though its pathophysiology remains unclear and testing is often difficult because of its short half-life. This case highlights that acute vasculitis can present atypically, even with peripheral neuropathy as the first major symptom, and can closely mimic infection. It also underscores the importance of detailed social history, chart review, and maintaining a broad differential during hospital readmissions. The patient was treated with pulse-dose steroids and rituximab.

Asset Subtitle

Jerryl P. Abraham

Meta Tag

Author List Darlene Lefrancois, Jerryl P. Abraham, Yolanda Yu

Category Clinical Vignettes

Concept Vasculitis

Concept Peripheral Neuropathy

Concept ANCA-Associated Vasculitis

Concept Stocking-Glove Distribution

Concept Cocaine Use

Distinguished Non-Finalist

Presenter Organization Montefiore Medical Center

Presenting Author Jerryl P. Abraham

Track Adult

Keywords

levamisole-adulterated cocaine

vasculitis

peripheral neuropathy

pauci-immune glomerulonephritis

leukocytoclastic vasculitis

cocaine use

acute kidney injury

diagnostic momentum

spinal abscess mimic

rituximab

Vasculitis

Peripheral Neuropathy

ANCA-Associated Vasculitis

Stocking-Glove Distribution

Cocaine Use