Case Presentation:

A 43‐year‐old healthy woman presented with painful lower‐extremity ulcers. Six weeks earlier, she had noticed a single red lesion on her left ankle. Over the next few weeks, the lesion enlarged, turned purple, and became exquisitely tender. Similar lesions appeared on her hips, buttocks, and ears. An outpatient skin biopsy revealed vasculopalhy of the small vessels with thrombi but no vasculitis, and she was empirically started on oral prednisone. Despite This treatment, the lesions increased in size and developed painful ulcerations, resulting in hospitalization. At that time, her exam was normal except for large palpable retiform purpura with central ulceration on her lower extremities and purpuric bullae on both ears. Inpatient workup revealed positive p‐ANCA, anti myeloperoxidase (MPO) antibodies, anticardiolipin antibodies, and lupus anticoagulant. A repeat skin biopsy again showed a small vessel vasculopathy without vasculitis. Malignancy workup was negative, and a transthoracic echocardiogram was normal. Urine toxicology was positive for cocaine. Her symptoms improved without intervention, but she was readmitted 3 weeks after discharge for persistent lower‐extremity pain because of worsening ulcerations and a dropping absolute neutrophil count (ANC) to 560/μL. Peripheral blood morphology was normal, and serologies for HIV, hepalitis, CMV, EBV, and parvovirus were negative. Urine toxicology was again positive for cocaine. Her constellation of retiform purpura without true vasculitis and agranulocytosis were believed to be most consistent with exposure to levamisole adulterated cocaine. One week after discharge, the patient's lower‐extremity pain and ulcerations were significantly improved, her ANC had increased to 2820/μL, and her urine toxicology screen was negative.


Levamisole is an antihelminthic used to treat cattle, sheep, and swine. It is used in India to treat steroid‐dependent nephritic syndrome in children. Pediatric case reports link therapeutic levamisole to cutaneous pseudovasculitis with associated purpura of the ears, positive ANCA, and positive antiphospholipid antibodies. Levamisole is no longer approved for human use in the United States, but it may potentiate the euphoric effects of cocaine and is now detectable in up to 70% of U.S. cocaine samples. At least 20 confirmed cases of agranulocytosis and 2 deaths have been associated with Ievamisole‐aduIterated cocaine. The U.S. Department of Health and Human Services issued a public health alert in September 2009 warning of an increase in levamisole‐related illness as a result of adulterated cocaine. Avoidance of further exposure is the only definitive treatment for the sequelae of levamisole toxicity.


Hospital‐based clinicians should be aware that levamisole‐adulterated cocaine can cause purpura and skin ulcerations as well as life threatening agranulocytosis. When evaluating presumed vasculitis, clinicians should maintain a high index of suspicion for cocaine use.

Author Disclosure:

J. Wei, none; P. Kneeland, none.