Rheumatic Manifestations of Cocaine Use

Jonathan Graf


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

In This Article


The pathogenesis of this syndrome is unknown. When used therapeutically, levamisole was linked to neutropenia, purpura of the cheeks and ears, ANCA and antiphospholipid antibodies, with many of these adverse events occurring in the setting of long- term use.[37–43] This suggests that prolonged exposure to levamisole alone is sufficient to induce these symptoms. There may be one or more mechanisms by which this might occur. Levamisole may be directly toxic to neutrophils or endothelial cells, may act as a nonspecific immune adjuvant in individuals predisposed to autoimmunity or may induce loss of tolerance to specific autoantigens in a manner that initiates or perpetuates autoimmunity. In an article published before the discovery of ANCA, investigators demonstrated that levamisole could induce IgM-specific granulocytoxic antibodies.[44] Cocaine itself is also associated with ANCA and leukocytoclastic vasculitis. The relevance of concomitant exposure to cocaine and levamisole is not known nor is the importance of underlying patient genetics or other epidemiologic factors that include potential exposure to as-of-yet uncharacterized adulterants or substances.