Case Presentation:

A 41–year–old female with a history of substance abuse presented to the Emergency Department with 1 month of bilateral lower extremity rash and severe pain. On arrival patient had altered mental status, met SIRS criteria of fever and tachycardia, and was leukopenic with an ANC of 1600. The rash was purpuric with bullous and necrotic areas and an erythematous macule was noted on the right ear. Workup was notable for P–ANCA positivity at a titer of 1:2650 and polyreactivity to MPO Ab and PR3. Urine drug screen was positive for cocaine metabolites. Thigh skin biopsy 3 months prior from an outside hospital 3 months revealed levamisole–associated thrombotic vasculitis. Vancomycin was empirically started for suspicion of MRSA super–infection and supportive care was provided with volume resuscitation, anti–pyretics, and wound care. Patient was discharged home and remains free from cocaine abuse at this time.


This is the ninth confirmed case of levamisole–associated thrombotic vasculitis at our hospital. Levamisole was historically used as an immunomodulator in rheumatoid arthritis and colon cancer until its withdrawal from the US market in 2000 due to agranulocytosis. The synthetic imidazothiazole derivative continues to be used today as an effective antihelminthic in veterinary medicine, and outside the US for childhood nephrotic syndrome. In 2010, it was found as a contaminant in 78% of cocaine at this safety net hospital. The clinical presentation of levamisole–associated thrombotic vasculitis includes characteristic retiform purpura with propensity for pinna involvement, high–titer ANCAS reactive to multiple target antigens, and frequently neutropenia. Treatment for this condition is not well established and remains largely supportive.


Unless targeted efforts to eradicate levamisole laced cocaine are undertaken, cases like this may become a common presentation of cocaine abuse. Epidemiologic data for the Midwest and Western US indicates increasing prevalence of levamisole–adulterated cocaine. Unfortunately, cocaine and crack use is the second–most common illicit drug–associated cause of ED visits in the Denver metro area. There is need for a robust public health campaign targeted at cocaine users regarding this life–threatening and potentially deforming drug related complication. Although we are in the initial stages of organizing our “Not all it’s cracked up to be” initiative at Denver Health, our patient education poster (image) hangs on the walls of our medicine ward and has begun to spread the word.

Figure 1Patient education poster.