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For further information, see CMDT Part 20-23: Levamisole-Associated Purpura

Key Features

  • Levamisole is a prevalent adulterant of illicit cocaine in North America

  • Exposure can induce a distinctive clinical syndrome of retiform purpura and cutaneous necrosis affecting the

    • Extremities

    • Ears

    • Skin overlying the zygomatic arch

  • Long-term sequelae of levamisole exposure include

    • Deforming cutaneous lesions

    • Arthralgias

    • Arthritis

Clinical Findings

  • The syndrome is associated with

    • The lupus anticoagulant

    • IgM antibodies to cardiolipin

    • Very high titers of p-ANCAs (due to autoantibodies to elastase, lactoferrin, cathepsin-G, and other neutrophil components rather than to myeloperoxidase alone)

  • Use of levamisole-adulterated cocaine also has been linked to

    • Neutropenia

    • Agranulocytosis

    • Pauci-immune glomerulonephritis


  • Biopsies reveal widespread thrombosis of small cutaneous vessels with varying degrees of vasculitis


  • There is no consensus on treatment, but early lesions can resolve with abstinence

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