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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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Autores principales: Veronese, F.V., Dode, R.S.O., Friderichs, M., Thomé, G.G., da Silva, D.R., Schaefer, P.G., Sebben, V.C., Nicolella, A.R., Barros, E.J.G.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Associação Brasileira de Divulgação Científica 2016
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4849970/
https://www.ncbi.nlm.nih.gov/pubmed/27119429
http://dx.doi.org/10.1590/1414-431X20165244
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author Veronese, F.V.
Dode, R.S.O.
Friderichs, M.
Thomé, G.G.
da Silva, D.R.
Schaefer, P.G.
Sebben, V.C.
Nicolella, A.R.
Barros, E.J.G.
author_facet Veronese, F.V.
Dode, R.S.O.
Friderichs, M.
Thomé, G.G.
da Silva, D.R.
Schaefer, P.G.
Sebben, V.C.
Nicolella, A.R.
Barros, E.J.G.
author_sort Veronese, F.V.
collection PubMed
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.
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spelling pubmed-48499702016-05-04 Cocaine/levamisole-induced systemic vasculitis with retiform purpura and pauci-immune glomerulonephritis Veronese, F.V. Dode, R.S.O. Friderichs, M. Thomé, G.G. da Silva, D.R. Schaefer, P.G. Sebben, V.C. Nicolella, A.R. Barros, E.J.G. Braz J Med Biol Res Case Report 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. Associação Brasileira de Divulgação Científica 2016-04-26 /pmc/articles/PMC4849970/ /pubmed/27119429 http://dx.doi.org/10.1590/1414-431X20165244 Text en http://creativecommons.org/licenses/by/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
spellingShingle Case Report
Veronese, F.V.
Dode, R.S.O.
Friderichs, M.
Thomé, G.G.
da Silva, D.R.
Schaefer, P.G.
Sebben, V.C.
Nicolella, A.R.
Barros, E.J.G.
Cocaine/levamisole-induced systemic vasculitis with retiform purpura and pauci-immune glomerulonephritis
title 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_short 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
topic Case Report
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4849970/
https://www.ncbi.nlm.nih.gov/pubmed/27119429
http://dx.doi.org/10.1590/1414-431X20165244
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