期刊名称：Journal of Education and Teaching in Emergency Medicine
印刷版ISSN：2474-1949
出版年度：2019
卷号：4
期号：3
页码：1-2
DOI：10.21980/J8K35S
出版社：University of California Press
摘要：History of present illness: A 65-year-old male with a past medical history of hypertension presented to the
emergency department with a rash on both of his thighs and legs for the last ten days. The patient stated
that he initially developed blisters on both of his knees, which then popped and scabbed over. He then
noticed the gradual onset of a purple rash over his kneesthat was painful and warm to the touch. The patient
reported cocaine use for the past two months but reported that he stopped after he noticed the blisters
because he had previously been hospitalized for a similar condition in 2013. His rash at that time was
attributed to an adulterant in the cocaine. He stated that in 2013 he required a several-day hospital stay for
renal injury. On exam, his vitalsigns were within normal limits and he was afebrile. Lab workup wassignificant
for a serum creatinine of 3 mg/dL (previous baseline 1.0 mg/dL) and a hemoglobin level of 7.4 g/dL (baseline
between 8 and 9 g/dL).
Significant findings: An asymmetric pattern of palpable purpura with bullae was noted on bilateral lower
extremities with smaller patches on bilateral upper extremities. There was no tenderness or crepitus.Discussion: In 2009, the drug enforcement administration (DEA) reported that 30% of seized cocaine was
found to be cut by Levamisole, which is thought to be primarily used as a diluent.1 Levamisole is an immune
modulator and anthelminthic agent used in the 1970’s as a therapy for conditions like rheumatoid arthritis,
pediatric nephrotic syndrome, and breast cancer. Its use was discontinued when patients began exhibiting
serious side effects including agranulocytosis, thrombocytopenia, arthritis, vasculitis and skin necrosis.2
These side effects predominantly occurred in women and had a mean age of incidence of 44 years when used
as an immunomodulatory agent.3 Levamisole-induced vasculitis hassince become an increasingly recognized
complication of cocaine use. It commonly presents with fever, myalgias, arthralgias and skin findingsthat can
include purpura, petechiae, subcutaneous nodules, bullae and necrosis.4 The most common complication is
the need for surgical consultation and debridement if the vasculitis leads to skin necrosis. Our patient
presented with an acute kidney injury; however, this is not widely reported in other case studies.
Treatment is largely supportive, although agents such as steroids, nonsteroidal anti-inflammatory drugs
(NSAIDs) and colchicine have reportedly been used.5 Disposition is variable and largely depends on the
severity of vasculitis and resulting skin findings. The patient should be encouraged to stop cocaine use given
a high likelihood of re-exposure to Levamisole. The patient presented in this case was admitted to the
hospital due to both his skin findings and acute kidney injury. His lesions and renal injury improved over time
and he was discharged home.
