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Retiform Purpura of the Lower Limbs Associated with Levamisole-Adulterated Cocaine

A young man was treated in hospital for sepsis, disseminated intravascular coagulation and multi-organ failure. He was a regular intranasal cocaine user up to 1 day prior to symptom onset. Clinical examination revealed extensive retiform purpura affecting both his lower limbs. Skin biopsy revealed w...

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Autores principales: Farrugia, Stephanie, Micallef, Daniel, Pisani, David, Betts, Alexandra, Vella, Sandro, Boffa, Michael J
Formato: Online Artículo Texto
Lenguaje:English
Publicado: SMC Media Srl 2022
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9067424/
https://www.ncbi.nlm.nih.gov/pubmed/35520371
http://dx.doi.org/10.12890/2022_003353
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author Farrugia, Stephanie
Micallef, Daniel
Pisani, David
Betts, Alexandra
Vella, Sandro
Boffa, Michael J
author_facet Farrugia, Stephanie
Micallef, Daniel
Pisani, David
Betts, Alexandra
Vella, Sandro
Boffa, Michael J
author_sort Farrugia, Stephanie
collection PubMed
description A young man was treated in hospital for sepsis, disseminated intravascular coagulation and multi-organ failure. He was a regular intranasal cocaine user up to 1 day prior to symptom onset. Clinical examination revealed extensive retiform purpura affecting both his lower limbs. Skin biopsy revealed widespread thrombosis in the small- and medium-sized vessels of the mid dermis and the subcutaneous fat with surrounding leucocytoclasis. There was also extensive ischaemic necrosis of the upper reticular and papillary dermis and focal ischaemic necrosis of the epidermis. These findings were in keeping with a thrombotic vasculopathy with associated cutaneous ischaemic necrosis, likely associated with levamisole-adulterated cocaine (LAC). An autoimmune screen showed extremely raised levels of anti-B2-glycoprotein IgM, IgG and anti-cardiolipin IgG antibodies, usually seen in antiphospholipid syndrome (APS). The literature describes how APS could be secondary to various underlying conditions, including LAC, and that levamisole toxicity may mimic APS and hence be missed. LEARNING POINTS: Levamisole is a common adulterant found in cocaine; the resultant toxicity can present with cutaneous manifestations, namely retiform purpura and skin necrosis, similar to antiphospholipid syndrome. Patients presenting with such features should be asked about illicit drug use, specifically cocaine, and investigated by screening urine for drugs of abuse and serum antihuman elastase antibody when possible.
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spelling pubmed-90674242022-05-04 Retiform Purpura of the Lower Limbs Associated with Levamisole-Adulterated Cocaine Farrugia, Stephanie Micallef, Daniel Pisani, David Betts, Alexandra Vella, Sandro Boffa, Michael J Eur J Case Rep Intern Med Article A young man was treated in hospital for sepsis, disseminated intravascular coagulation and multi-organ failure. He was a regular intranasal cocaine user up to 1 day prior to symptom onset. Clinical examination revealed extensive retiform purpura affecting both his lower limbs. Skin biopsy revealed widespread thrombosis in the small- and medium-sized vessels of the mid dermis and the subcutaneous fat with surrounding leucocytoclasis. There was also extensive ischaemic necrosis of the upper reticular and papillary dermis and focal ischaemic necrosis of the epidermis. These findings were in keeping with a thrombotic vasculopathy with associated cutaneous ischaemic necrosis, likely associated with levamisole-adulterated cocaine (LAC). An autoimmune screen showed extremely raised levels of anti-B2-glycoprotein IgM, IgG and anti-cardiolipin IgG antibodies, usually seen in antiphospholipid syndrome (APS). The literature describes how APS could be secondary to various underlying conditions, including LAC, and that levamisole toxicity may mimic APS and hence be missed. LEARNING POINTS: Levamisole is a common adulterant found in cocaine; the resultant toxicity can present with cutaneous manifestations, namely retiform purpura and skin necrosis, similar to antiphospholipid syndrome. Patients presenting with such features should be asked about illicit drug use, specifically cocaine, and investigated by screening urine for drugs of abuse and serum antihuman elastase antibody when possible. SMC Media Srl 2022-04-28 /pmc/articles/PMC9067424/ /pubmed/35520371 http://dx.doi.org/10.12890/2022_003353 Text en © EFIM 2022 This article is licensed under a Commons Attribution Non-Commercial 4.0 License
spellingShingle Article
Farrugia, Stephanie
Micallef, Daniel
Pisani, David
Betts, Alexandra
Vella, Sandro
Boffa, Michael J
Retiform Purpura of the Lower Limbs Associated with Levamisole-Adulterated Cocaine
title Retiform Purpura of the Lower Limbs Associated with Levamisole-Adulterated Cocaine
title_full Retiform Purpura of the Lower Limbs Associated with Levamisole-Adulterated Cocaine
title_fullStr Retiform Purpura of the Lower Limbs Associated with Levamisole-Adulterated Cocaine
title_full_unstemmed Retiform Purpura of the Lower Limbs Associated with Levamisole-Adulterated Cocaine
title_short Retiform Purpura of the Lower Limbs Associated with Levamisole-Adulterated Cocaine
title_sort retiform purpura of the lower limbs associated with levamisole-adulterated cocaine
topic Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9067424/
https://www.ncbi.nlm.nih.gov/pubmed/35520371
http://dx.doi.org/10.12890/2022_003353
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