Adult Female With Rash on Lower Extremities

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A 44-year-old woman presented with a rash on her bilateral lower extremities, abdomen, and face. The lesions started 1 week ago in her lower extremities and spread proximally, sparing mucus membranes. Five days ago, she sought medical care for the rash and was prescribed bactrim, which yielded no improvement. The patient endorsed cocaine use for the past week. On physical examination, the patient had multiple stellate, purpuric macules, and plaques with central necrosis and erythematous borders (Figure 1, Figure 2). Initial studies included an absolute neutrophil count of 270/mm³.

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• Figure 1. 

  Skin lesion, bilateral legs.

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• Figure 2. 

  Skin lesions, abdomen

Used with permission of Kenny Banh, MD, Department of Emergency Medicine, University of California San Francisco-Fresno, Fresno, CA.

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Diagnosis 

Vasculopathic purpura and neutropenia caused by levamisole-contaminated cocaine. The characteristic skin lesions, neutropenia, and temporal association with cocaine use warranted investigation for levamisole exposure. Biopsy showed extensive thrombotic vasculopathy. The patient's urine and serum were studied with a liquid-chromatography tandem mass spectrometry method and were found to be positive for levamisole in both specimens.

Levamisole is an antihelminthic with immunomodulatory properties that is rarely used in humans. For an unknown reason, levamisole is now found in as much as 70% of cocaine in the United States.¹ It has been implicated in cases of neutropenia and agranulocytosis across North America.², ³, ⁴ Levamisole also causes vasculopathic purpura. Skin biopsy yields a range of vasculopathic changes, including thrombotic vasculitis, leukocytoclastic vasculitis, or vascular occlusion.⁵ Cases of these lesions occurring in association with cocaine use have been reported.⁶ To our knowledge, this case is the first with laboratory verification. No particular treatment is necessary besides cessation of levamisole exposure. However, the characteristic skin lesion serves as a harbinger for levamisole exposure and its more serious adverse effect of neutropenia.

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References 

1. Hitt E. Cocaine laced with levamisole increasing, poses risk for agranulocytosis. Medscape. http://www.medscape.com/viewarticle/709451?src=rssAccessed September 24, 2009
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2. Buchanan JA, Patel NR, Jacquet GA, et al. A confirmed case of agranulocytosis after use of cocaine contaminated with levamisole. J Med Toxicol. In press.
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3. Centers for Disease Control and Prevention. Agranulocytosis associated with cocaine use—four states March 2008–November 2009. MMWRMorb Mortal Wkly Rep. 2009;58:1381–1385
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4. Knowles L, Buxton JA, Skuridina N, et al. Levamisole tainted cocaine causing severe neutropenia in Alberta and British Columbia. Harm Reduct J. 2009;6:30
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5. Rongioletti F, Ghio L, Ginevri F, et al. Purpura of the ears: distinctive vasculopathy with circulating autoantibodies complicating long-term treatment with levamisole in children. Br J Dermatol. 1999;140:948–951
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6. Waller JM, Feramisco JD, Alberta-Wszolek L, et al. Cocaine-associated retiform purpura and neutropenia: is levamisole the culprit? J Am Acad Dermatol. In press.
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