Levamisole-induced leukocytoclastic vasculitis and neutropenia in a patient with cocaine use: An extensive case with necrosis of skin, soft tissue, and cartilage

According to July 2009 estimates, 69% of the cocaine seized by the US Drug Enforcement Administration (DEA) is adulterated with levamisole [1,2]. Levamisole is a veterinary antihelminthic agent that has recently been linked to vasculitis and neutropenia in people with cocaine use [3,4]. We describe a cocaine user with levamisole-induced necrosis of the skin, soft tissue, and cartilage resulting in nasal amputation, earlobe necrosis, and bilateral above-knee amputation (AKA). To the best of our knowledge, this is only the second case of levamisole-induced vasculitis requiring above-knee amputation to be reported in the English language literature, and it is also one of the first reported cases with laboratory confirmation of levamisole exposure.A 44-year-old African American woman with history of hypertension and asthma presented to the hospital with a complaint of a painful rash on her extremities of 2-3 months’ duration. The rash first appeared on her upper extremities and then progressed to her legs, cheeks, nose, and earlobes. She denied a history of fever, weight loss, alopecia, dry mouth, oral ulcers, painful red eyes, photosensitivity, myalgia, arthralgia, joint swelling, dysphagia, miscarriages, or blood clots. The patient had a chronic history of crack cocaine use and a smoking history of five pack-years. On examination, her vital signs were stable. Skin examination revealed erythematous maculopapular purpuric lesions on her nose, cheeks, and earlobes with central blackish discoloration (Figures 1 and 2). She had several large violaceous plaques and flaccid bullae on her upper and lower extremities and a stage-II ulcer on the medial surface of her right ankle with some serosanginuous discharge. Other physical examination results were normal.Laboratory investigations revealed leukopenia with a white blood cell count (WBC) of 2,600 cells/μL, neutropenia with an absolute neutrophil count (ANC) of 900 cells/μL, an elevated erythrocyte sedimentation rate (ESR) of