Levamisole abuse
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Vasculitis in the lower extremities: case report A 60-year-old woman developed vasculitis in the lower extremities following abuse of levamisole. The woman presented with multiple bilateral lower-extremity ulcerations. At presentation, she was distressed and was screaming, with her pain rating 10/10. She had been experiencing the pain for several months. Her condition was worsening progressively. The pain was sharp and diffuse, and worsened with movement. The ulcerations developed initially as red spots all over her legs, and then became larger and blackened with weep drainage. Two weeks prior the current presentation, she was evaluated at emergency department twice. After the first visit, she was discharged on doxycycline. At the second presentation, she received a 10-day course of cefalexin, and then she was discharged. Her medical history was significant for hepatitis C, chronic kidney disease and IV drug use. She used free base cocaine daily for 10 years. Her cocaine was adulterated with levamisole [route and amount administered not stated]. At the current presentation, clinical examination showed black necrotic multiple bilateral lower extremity dry ulcerations with peri-ulcerative erythema. There were several wounds draining serous exudates. Neurologic examination was intact to light touch and pulses were palpable bilaterally. Laboratory investigations showed thrombocytopenia, anaemia and neutropenia. Her chemistry panel showed elevated levels of creatinine and blood urea nitrogen. Pathology results of the left medial malleolus wound showed fragments of keratin, necrosis and abundant bacterial cocci and benign fibrous tissue with inflammatory cells. Gram’s stain showed rare to occasional polymorphonuclear cells, occasional mononuclear cells, few gram-positive cocci in pairs, and few gramnegative rods. Levamisole-induced vasculitis was considered. The woman received local wound care regimen and her use of cocaine, which was adulterated with levamisole, was restricted. The ulcers were dressed with cohesive bandage, gauze bandage, non-adhesive silicon foam dressing and povidone iodine. Consequently, the wounds improved. She was admitted for management of her multiple comorbidities. After a 3-day hospital stay, she was discharged to a skilled nursing facility for wound care and continued rehabilitation. However, she was expelled from the skilled nursing facility for selling and distributing cocaine. She was then discharged to the home health nursing for continued wound care. Two months later, she returned to the emergency department with complaints of painful ulcerations. Although, she had not stopped using cocaine, mild improvement in her ulcerations was noted. Nguyen V, et al. Levamisole-Induced Vasculitis in the Lower Extremities: A Case Report. Journal of the American Podiatric Medical Association 109: 150-154, No. 2, Mar 803448457 2019. Available from: URL: http://doi.org/10.7547/17-047
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