Levamisole abuse
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Pyoderma gangrenosum: case report A 64-year-old man developed pyoderma gangrenosum (PG) following abuse of levamisole adulterated cocaine [dosage, route and duration of treatment to reaction onset not stated]. The man with a history of cocaine abuse and chronic rhinosinusitis presented with 10 months history of recurrent boils, which worsened during the periods of cocaine use. For the presumed recurrent bacterial folliculitis, he received several courses of unspecified antibacterials [antibiotics], but he continued to developed new lesions. The man’s two lesions were excised, which healed briefly. After several weeks, ulcers occurred in the same areas, indicated that pathergy was at play. He was referred to dermatology. Physical examination showed multiple exquisitely tender ulcers (measuring up to 10cm) involving the torso, arms, face, legs, groin and scalp. The ulcerations were deep into the fat in multiple locations and were characterised by undermined borders with purulence and fibrinoid exudate at the bases and gunmetal-gray rims, erythematous oedematous surrounding skin. Histopathology showed dermal granulomatous and suppurative inflammatory infiltrates comprising of histiocytes, lymphocytes and multinucleated giant cells with focal underlying fat necrosis and extensive neutrophilic abscess formation with no evidence of vasculopathy or vasculitis. Acid-fast bacilli, periodic acid-Schiff, gram and Treponema pallidum immunostaining were negative. His tissue cultures for fungus, bacteria and acid-fast bacilli were negative. His c-antineutrophil cytoplasmic antibody titre was 1:2560 and result was positive for dilute Russell viper venom time indicative of the presence of lupus anticoagulant. Based on the pathergy, classic morphological features, history of illicit drug use and histologic findings, he was diagnosed with levamisole-adulterated cocaine-induced PG. He was initially treated with prednisone with marginal improvement. Thereafter, dapsone was added to the treatment. After initial improvement with steroids treatment, prednisone tapering was attempted, but flaring of his PG was observed. Hence, he was started on infliximab infusions. Due to suboptimal response, azathioprine was added to the treatment. Thereafter, his care was transferred to a wound care specialist. The wound care specialist discontinued all the immunosuppressants, and started him on topical therapy. After the several weeks, he was admitted due to adrenal insufficiency and intractable pain. The intractable pain was associated with widespread eruption of cutaneous lesions. He was treated with IV methylprednisolone for 3 days followed by ciclosporin 200mg twice a day with a significant improvement. For his adrenal insufficiency. he was started on prednisone. However, he developed acute renal injury secondary to ciclosporin. Hence, ciclosporin was discontinued. Along with the weekly drug monitoring, he was started on adalimumab with a significant improvement after 2 weeks. After initial 90% of improvement, his lesions reoccurred. Hence, o
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