A 50-year-old female with a history of bipolar disorder, ADHD, anxiety, depression, and alcoholism presented to the ED after her family found her at home agitated, restless, and with a “large black burn” on her face. Her husband reported that she had been “picking” at this area of her face earlier in the day; at that time it appeared only slightly red. Per her husband, the patient had also felt “bugs crawling on her legs” and had been picking at and grabbing her legs on the day of presentation.
Vitals: Temp: 97.7 F, pulse 50, resp 20, BP 147/117, SaO2 94% on room air
General: Awake, agitated, not directable, moving all extremities
HEENT: Eschar over left cheek extending to hairline at temple, and eschar over anterior nose
Lungs: Clear to auscultation bilaterally
Heart: Regular rate and rhythm, no murmurs, gallops, or rubs
Abdomen: Soft, non-tender, non-distended
Rectal: No trauma or frank blood
Skin: Warm and dry, scattered ecchymosis on arms and legs bilaterally
Neuro: 5/5 strength, alert and oriented x1
CBC: WBC 27.5 with 89.2% Neutrophils
BMP: Na 134 mmol/L, K 5.2 mmol/L, Cl 93 mmol/L, Cr 8.0 mg/dL, BUN 57 mg/dL, CO2 8 mmol/L
LFTs: AST 375 U/L, ALT 156 U/L
CK: 16,655 U/L
Lactic acid: 2.2 mmol/L
Procalcitonin: 17.45 ng/mL
Arterial pH: 7.195
Arterial pCO2: 21.3 mmHg
Urinalysis: Positive for protein and RBCs
Tox screen: Cocaine metabolites (urine) positive
This pattern of retiform purpuric rash with erythematous borders and central necrosis over the cheeks, ears, and nasal tip is characteristic of levamisole-induced vasculitis.
Levamisole is a veterinary anthelmintic agent that was previously used in treatment of some cancers and rheumatoid arthritis due to its immunomodulating effects. It was banned by the US Food and Drug Administration in 2000 because of its side effects, including vasculitis and agranulocytosis.
Levamisole has been used as an adulternate in cocaine to “cut” the drug.
- Levamisole-induced vasculitis is associated with cocaine use.
- Patients with levamisole-induced vasculitis present with painful purpuric rash in a retiform or stellate pattern, often with central necrosis or bullae, on the digits, extremities, trunk, nasal tip, cheek, and ears.
- Laboratory findings associated with levamisole-induced vasculitis include leukopenia, neutropenia, agranulocytosis, elevated ESR, and positive anti-nuclear antibodies.