Rheumatic Manifestations of Cocaine Use

Jonathan Graf


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

In This Article

Recent Experience

Cocaine/levamisole-associated rheumatic disease is a newly reported phenomenon, and the extent of its clinical phenotype has likely yet to be fully characterized. Although described primarily as a cutaneous disease, it is conceivable that levamisole-adulterated cocaine is associated with other severe extracutaneous manifestations. Previously, levamisole has been implicated in the development of proliferative glomerulonephritis in a patient with rheumatoid arthritis,[46] and a recent series describes pulmonary haemorrhage as a possible consequence of exposure to levamisole-tainted cocaine.[36] Because both cocaine and levamisole can induce ANCA (perhaps in the absence of clinical disease), it is difficult to definitively know whether or not these drugs were directly involved in these cases or whether these patients developed unrelated idiopathic disease but were coincidentally ANCA positive by virtue of their exposure to cocaine and/or levamisole.

In the time since we reported our initial experience with six patients exposed to levamisole-adulterated cocaine, we have observed other patients develop interesting autoimmune phenomena in the setting of cocaine use and high-titre p-ANCA. One male patient presented with a pauci-immune glomerulonephritis, retiform purpura and digital infarcts. Because he had manifestations of both classic skin involvement and renal disease, it is likely that these phenomena were related to his exposure to levamisole and/or cocaine. Another patient developed alveolar haemorrhage and a pauci-immune glomerulonephritis in the setting of high-titre p-ANCA but without classic retiform purpura. In her case, antibodies to MPO were significantly positive, in contrast to many other patients with levamisole-associated autoimmunity. Both of these patients have been treated with corticosteroids and intravenous cyclophosphamide.