Levamisole
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Pyoderma gangrenosum like facial ulcers: case report A 30-year-old woman developed pyoderma gangrenosum-like facial ulcers following abuse of levamisole adulterated cocaine [route, quantity of administration and duration of treatment to reaction onset not stated]. The woman, who had a history of cocaine use, developed enlarged facial ulcers with necrotic-appearing centres and violaceous peripheral borders on face, arms and back without involvement of the ears and oral cavity. She had headaches, intermittent fever and anxiety. Previously, she was treated with broad spectrum antibiotics comprising vancomycin and cotrimoxazole [trimethoprim/ sulfamethoxazole] and an unspecified cephalosporins without significant effect on wound healing. Thereafter, she presented to an academic medical centre. Biopsy of the face, body ulcers, wound centres and borders revealed neutrophil-rich and lymphocyte-rich dermal inflammation without clear evidence of vasculitis or vasculopathy. Infectious aetiologies were found to be negative for bacterial, viral, fungal, or mycobacterial organisms. Urinalysis showed intermittent haematuria (initially positive, then negative on repeat test). Laboratory investigations revealed elevated levels of CRP and erythrocyte sedimentation rate. Urine toxicology was found to be positive for cocaine use. Serology for autoantibodies revealed positive findings for cytoplasmic anti-neutrophil cytoplasmic antibody antiproteinase-3 (cANCAs/anti-PR3). CT imaging showed radiologic evidence of a nasal septal defect, indicated a history of cocaine use. Chest CT showed small pulmonary nodules, which were found to be stable on repeated imaging. The woman was hospitalised and was treated with methylprednisolone over the course of 3 days, which was tapered later. Then she was started on rituximab infusions. Fourteen days later, when she was complied with the first dose, she received the second dose of rituximab. Rituximab was then discontinued due to non compliance with infusions on an out-patient basis. Two months later, she was admitted again for another round of steroids, rituximab and prophylactic cotrimoxazole. Following this treatment, ulcers healed with scarring and scant overlying crust. She was counselled regarding attribution of cocaine to her disease and advised to stop the drug use. She was referred for multispecialty outpatient follow-up to monitor healing and any potential systemic involvement. Then, she lost to follow-up for 1 year. By the time, she restarted the cocaine use and had relapse of the disease. She presented to the emergency room again with worsened clinical presentation. Facial ulcerations were reformed at the same locations along with new locations at the back, arms and genital areas, and became larger in size. Clinical findings were mimicking granulomatosis with polyangiitis. Oral evaluation showed strawberry gums and saddle-nose deformity. Urine toxicology was positive for cocaine. There were no evidences of renal involvement. Elevation in CRP and erythrocyte sedimentation rate were no
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