SHM Converge Scientific Abstract ePoster Gallery-Purpuric Rash: Levamisole-Contaminated Cocaine-Induced Vasculitis

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This case describes a 35-year-old woman with polysubstance use, including cocaine, who was found down at home and admitted with altered mental status. She required intubation for airway protection and was noted to have bullous and gangrenous lesions on her toes, along with purpuric lesions on the hip and forearm. Her labs showed severe acute kidney injury, rhabdomyolysis, and inflammation, and urine drug screening was positive for cocaine and several other substances.<br /><br />Because cocaine is often contaminated with levamisole, the team considered levamisole/cocaine-induced vasculitis, a syndrome associated with ANCA positivity and skin necrosis. Her autoimmune workup was positive for c-ANCA and PR-3. However, kidney biopsy did not show ANCA-associated glomerulonephritis; instead, it demonstrated acute tubular necrosis. Blood cultures and echocardiogram were negative, and chest CT showed left lung consolidation.<br /><br />During hospitalization, she developed acute renal failure requiring hemodialysis and aspiration pneumonia treated with broad-spectrum antibiotics. She improved enough to be weaned off the ventilator. Management of the suspected vasculitis was largely supportive, and steroids were not started because there was no clear end-organ damage from vasculitis. Despite stabilization of her kidney function, the ischemic skin injury progressed, and she ultimately required amputation of four toes due to gangrene.<br /><br />This case highlights both typical and atypical features of levamisole/cocaine-induced vasculitis. While skin involvement is common, lesions usually affect the face and trunk; in this patient, the hands and feet were more prominently involved. The report emphasizes that clinicians should consider this diagnosis in patients with cocaine use and unexplained skin lesions, while treatment decisions depend on the presence of neutropenia, infection risk, and evidence of organ involvement.

Asset Subtitle

Babray Laek

Meta Tag

Author List Anjana Chandrasekhara Pillai, Babray Laek, Khushboo Singh, Tissa Bijoy George

Category Clinical Vignettes

Concept Levamisole

Concept Cocaine

Concept ANCA-Associated Vasculitis

Concept Cutaneous Manifestation

Concept Skin Lesion

Distinguished Non-Finalist

Presenter Organization UPMC McKeesport

Presenting Author Babray Laek

Track Adult

Keywords

levamisole

cocaine

vasculitis

ANCA

c-ANCA

PR-3

skin necrosis

gangrene

acute kidney injury

rhabdomyolysis

Levamisole

Cocaine

ANCA-Associated Vasculitis

Cutaneous Manifestation

Skin Lesion