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For further information, see CMDT Part 22-23: 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

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

    • Neutropenia

    • Agranulocytosis

    • Pauci-immune glomerulonephritis

  • Autoantibody positivity is common with the presence of

    • Lupus anticoagulant

    • IgM anti-cardiolipin antibodies

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

    • However, autoantibody positivity is due to toxic exposure to levamisole and not to the presence of an underlying rheumatic condition

DIAGNOSIS

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

TREATMENT

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

  • Long-term sequelae of levamisole exposure may include deforming cutaneous lesions

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