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 Hydrochloride]

  • 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.
Samuel Southgate

Samuel Southgate

Medical Student
University of Connecticut School of Medicine
Samuel Southgate

Latest posts by Samuel Southgate (see all)

Meghan Herbst, MD

Meghan Herbst, MD

Associate Professor
Department of Emergency Medicine
University of Connecticut School of Medicine
Meghan Herbst, MD

Latest posts by Meghan Herbst, MD (see all)