Rheumatic Manifestations of Cocaine Use

Jonathan Graf


Curr Opin Rheumatol. 2013;25(1):50-55. 

In This Article

Levamisole-associated Rheumatic Disease

Levamisole is a veterinary antihelminthic medication previously used to treat paediatric nephrotic syndrome, rheumatoid arthritis and colon cancer before being withdrawn from the market because of significant toxicity that included neutropenia. Beginning in 2008–2009, reports surfaced describing severe cases of neutropenia, some of them fatal, occurring in patients who were exposed to cocaine adulterated with levamisole.[26–28] The timing of these cases is most likely linked to the dramatic increase in use of levamisole as a cocaine adulterant. According to the US Drug Enforcement Agency, as much as 70% of the cocaine seized in 2009 contained levamisole compared with fewer than 5% of the cocaine seized in 2007.[29] Currently, there is no widely available, standardized test for levamisole exposure, but it can be detected in specialized laboratories using liquid chromatography/tandem mass spectroscopy.[30,31] Two separate case series from inner-city hospitals detected levamisole in 68—88% of urine samples from confirmed cocaine-positive patients.[30,31] The exact reason for this dramatic increase in levamsiole as an adulterant of cocaine is not fully understood.

Exposure to levamisole-adulterated cocaine is also associated with a distinct clinical syndrome characterized primarily by retiform purpura, cutaneous necrosis, thrombotic angiopathy of small dermal vessels and autoantibodies that include high titres of p-ANCA and antiphospholipid antibodies.[6,32,33,34,35] Patients frequently demonstrate high levels of both ESR and CRP.[6] At first glance, this syndrome of purpura and positive p-ANCA might be confused with microscopic polyangiitis (MPA), but several clinical and laboratory features distinguish these two entities. Levamisole—cocaine associated rheumatic disease is primarily limited to the skin, although some suspected cases of extracutaneous involvement including pulmonary haemorrhage have been identified.[36] The purpura is retiform rather than palpable purpura and has a curious predilection for the ears, cheeks, zygomatic arch and lower extremities (Fig. 1).[6,33] Some patients may also have small digital infarctions (Fig. 2). In addition, neutropenia is commonly encountered in this syndrome in contrast to those patients with MPA.[6,34]

Figure 1.

Classic dermatologic manifestations of exposure to levamisole-adulterated cocaine. Retiform purpura with central area of necrosis surrounded by serpiginous erythema.

Figure 2.

Digital infarctions in a patient exposed to levamisole-adulterated cocaine.