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Kumar D, Batal I, Jim B, Mendez B, Anis K. Unusual case of levamisole-induced dual-positive ANCA vasculitis and crescentic glomerulonephritis. BMJ Case Rep 2018; 2018:bcr-2018-225913. [PMID: 30232205 DOI: 10.1136/bcr-2018-225913] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Cocaine adulterated levamisole is an increasingly reported cause of skin necrosis, arthralgia and systemic vasculitis, but renal involvement is uncommon. We present a case of a 40-year-old Hispanic man with a history of cocaine abuse who presented with acute kidney injury to the rheumatology clinic where he was being treated for chronic inflammatory arthritis. He was found to have a serum creatinine of 2.5 mg/dL, microscopic haematuria and subnephrotic proteinuria, along with positive proteinase 3, myeloperoxidase, anticardiolipin antibodies and an elevated antinuclear antibody titre. The renal pathology revealed focal necrotising glomerulonephritis with crescentic features and mild immune type deposition. The patient was treated with cocaine abstinence, pulse dose steroids followed by maintenance prednisone, rituximab and cyclophosphamide. His renal function subsequently improved but did not normalise. We believe that his incomplete improvement was due to the degree of kidney injury on presentation as well as recidivism with cocaine use.
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Affiliation(s)
- Dileep Kumar
- Department of Medicine, Jacobi Medical Center, Bronx, New York, USA
| | - Ibrahim Batal
- Department of Pathology, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Belinda Jim
- Department of Medicine, Jacobi Medical Center, Bronx, New York, USA
| | - Barbara Mendez
- Department of Medicine, Jacobi Medical Center, Bronx, New York, USA
| | - Kisra Anis
- Department of Medicine, Jacobi Medical Center, Bronx, New York, USA
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2
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Liu YWJ, Mutnuri S, Siddiqui SB, Weikle GR, Oladipo O, Ganti N, Beach RE, Afrouzian M. Levamisole-Adulterated Cocaine Nephrotoxicity: Ultrastructural Features. Am J Clin Pathol 2016; 145:720-6. [PMID: 27247374 DOI: 10.1093/ajcp/aqw029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The issue of levamisole-adulterated cocaine is emerging as a rapidly growing public health concern due to an increasing number of reports describing its role in cutaneous vasculitis and agranulocytosis. Of note, levamisole is recognized as a contaminant in 69% of the cocaine used within the United States. METHODS We describe a patient who was a chronic cocaine user and developed systemic vasculitis characterized by polyarthralgia, bullous skin lesions, agranulocytosis, and antineutrophil cytoplasmic antibody-positive rapidly progressive glomerulonephritis. RESULTS The skin biopsy specimen demonstrated leukocytoclastic vasculitis. The renal biopsy specimen revealed pauci-immune necrotizing and crescentic glomerulonephritis and unusual deposits with medium electron density composed of granules, microspherules, and rare single fibrils on electron microscopy. CONCLUSIONS The electron microscopic features of levamisole-adulterated cocaine toxicity are novel findings that are presented for the first time, to our knowledge, in this report.
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Affiliation(s)
- Yi-Wei Justin Liu
- From the Department of Internal Medicine, University of Southern California, Los Angeles
| | | | | | | | | | - Niharika Ganti
- Division of Rheumatology, University of Texas Medical Branch at Galveston
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3
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Veronese FV, Dode RSO, Friderichs M, Thomé GG, da Silva DR, Schaefer PG, Sebben VC, Nicolella AR, Barros EJG. Cocaine/levamisole-induced systemic vasculitis with retiform purpura and pauci-immune glomerulonephritis. ACTA ACUST UNITED AC 2016; 49:e5244. [PMID: 27119429 PMCID: PMC4849970 DOI: 10.1590/1414-431x20165244] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 03/03/2016] [Indexed: 11/29/2022]
Abstract
Levamisole has been increasingly used as an adulterant of cocaine in recent years,
emerging as a public health challenge worldwide. Levamisole-associated toxicity
manifests clinically as a systemic vasculitis, consisting of cutaneous,
hematological, and renal lesions, among others. Purpura retiform, cutaneous necrosis,
intravascular thrombosis, neutropenia, and less commonly crescentic nephritis have
been described in association with anti-neutrophil cytoplasmic antibodies (ANCAs) and
other autoantibodies. Here we report the case of a 49-year-old male who was a chronic
cocaine user, and who presented spontaneous weight loss, arthralgia, and 3 weeks
before admission purpuric skin lesions in the earlobes and in the anterior thighs.
His laboratory tests on admission showed serum creatinine of 4.56 mg/dL, white blood
count 3,800/μL, hemoglobin 7.3 g/dL, urinalysis with 51 white blood cells/μL and 960
red blood cells/μL, and urine protein-to-creatinine ratio 1.20. Serum ANCA testing
was positive (>1:320), as well as serum anti-myeloperoxidase and anti-proteinase 3
antibodies. Urine toxicology screen was positive for cocaine and levamisole, with
62.8% of cocaine, 32.2% of levamisole, and 5% of an unidentified substance. Skin and
renal biopsies were diagnostic for leukocytoclastic vasculitis and pauci-immune
crescentic glomerulonephritis, respectively. The patient showed a good clinical
response to cocaine abstinence, and use of corticosteroids and intravenous
cyclophosphamide. Last serum creatinine was 1.97 mg/dL, white blood cell count
7,420/μL, and hemoglobin level 10.8 g/dL. In levamisole-induced systemic vasculitis,
the early institution of cocaine abstinence, concomitant with the use of
immunosuppressive drugs in severe cases, may prevent permanent end organ damage and
associate with better clinical outcomes.
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Affiliation(s)
- F V Veronese
- Serviço de Nefrologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - R S O Dode
- Serviço de Nefrologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - M Friderichs
- Serviço de Nefrologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - G G Thomé
- Serviço de Nefrologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - D R da Silva
- Serviço de Nefrologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - P G Schaefer
- Serviço de Patologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - V C Sebben
- Centro de Informação Toxicológica, Fundação Estadual de Produção e Pesquisa em Saúde, Porto Alegre, RS, Brasil
| | - A R Nicolella
- Centro de Informação Toxicológica, Fundação Estadual de Produção e Pesquisa em Saúde, Porto Alegre, RS, Brasil
| | - E J G Barros
- Serviço de Nefrologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
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Levamisole/Cocaine Induced Systemic Vasculitis and Immune Complex Glomerulonephritis. Case Rep Nephrol 2015; 2015:372413. [PMID: 26290761 PMCID: PMC4531184 DOI: 10.1155/2015/372413] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 07/14/2015] [Indexed: 11/17/2022] Open
Abstract
Levamisole is an antihelminthic and immunomodulator medication that was banned by the USFDA in 1998. It has been increasingly used to adulterate cocaine due to its psychotropic effects and morphological properties. Adverse reactions including cutaneous vasculitis, thrombocytopenia, and agranulocytosis have been well described. Despite systemic vasculitis in this setting, renal involvement is uncommon. We report here a case of ANCA positive systemic vasculitis with biopsy proven immune complex mediated glomerulonephritis likely secondary to levamisole/cocaine. A 40-year-old Caucasian male with no past medical history presented with 3-week history of fatigue, skin rash, joint pains, painful oral lesions, oliguria, hematuria, worsening dyspnea on exertion, and progressive lower extremity edema. He had a history of regular tobacco and cocaine use. Lab testing revealed severe anemia, marked azotemia, deranged electrolytes, and 4.7 gm proteinuria. Rheumatologic testing revealed hypocomplementemia, borderline ANA, myeloperoxidase antibody, and positive atypical p-ANCA. Infectious and other autoimmune workup was negative. Kidney biopsy was consistent with immune mediated glomerulonephritis and showed mesangial proliferation and immune complex deposition consisting of IgG, IgM, and complement. High dose corticosteroids and discontinuing cocaine use resulted in marked improvement in rash, mucocutaneous lesions, and arthritis. There was no renal recovery and he remained hemodialysis dependent.
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Pendergraft WF, Herlitz LC, Thornley-Brown D, Rosner M, Niles JL. Nephrotoxic effects of common and emerging drugs of abuse. Clin J Am Soc Nephrol 2014; 9:1996-2005. [PMID: 25035273 DOI: 10.2215/cjn.00360114] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The kidneys can be injured in diverse ways by many drugs, both legal and illegal. Novel associations and descriptions of nephrotoxic effects of common and emerging drugs of abuse have appeared over the past several years. Anabolic androgenic steroids, illicitly used by athletes and others for decades to increase muscle mass and decrease body fat, are emerging as podocyte toxins given recent descriptions of severe forms of FSGS in long-term abusers. Synthetic cannabinoids, a new group of compounds with marijuana-like effects, recently became popular as recreational drugs and have been associated with an atypical form of AKI. 3,4-Methylenedioxymethamphetamine, commonly known as ecstasy, is a widely used synthetic recreational drug with mood-enhancing properties and a constellation of toxicities that can result in death. These toxic effects include hyperthermia, hypotonic hyponatremia due to its arginine vasopressin secretagogue-like effects, rhabdomyolysis, and cardiovascular collapse. Cocaine, a serotonin-norepinephrine-dopamine reuptake inhibitor that serves as an illegal stimulant, appetite suppressant, and anesthetic, also causes vasoconstriction and rhabdomyolysis. Recent adulteration of much of the world's supply of cocaine with levamisole, an antihelminthic agent with attributes similar to but distinct from those of cocaine, appears to have spawned a new type of ANCA-associated systemic vasculitis. This review discusses the nephrotoxic effects of these common and emerging drugs of abuse, of which both community and health care providers should become aware given their widespread abuse. Future investigation into pathogenetic mechanisms associated with these drugs is critical and may provide a window into ways to lessen and even prevent the nephrotoxic effects of these drugs of abuse and perhaps allow a deeper understanding of the nephrotoxicities themselves.
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Affiliation(s)
- William F Pendergraft
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Division of Nephrology, Department of Medicine, and Vasculitis and Glomerulonephritis Clinic, Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts
| | - Leal C Herlitz
- Division of Renal Pathology, Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Denyse Thornley-Brown
- Division of Nephrology, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama; and
| | - Mitchell Rosner
- Division of Nephrology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - John L Niles
- Division of Nephrology, Department of Medicine, and Vasculitis and Glomerulonephritis Clinic, Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts;
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Larocque A, Hoffman RS. Levamisole in cocaine: unexpected news from an old acquaintance. Clin Toxicol (Phila) 2012; 50:231-41. [PMID: 22455354 DOI: 10.3109/15563650.2012.665455] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Levamisole is a pharmaceutical with anthelminthic and immunomodulatory properties that was previously used in both animals and humans to treat inflammatory conditions and cancer. Levamisole has been identified as a cocaine adulterant in the United States since 2003. By 2009, the United States Drug Enforcement Administration (DEA) estimated that 69% of the cocaine seized contained levamisole. The first case reports of complications related to levamisole in cocaine users were published in 2009. The objectives of this article are to review the literature regarding the full spectrum of possible complications related to levamisole use for medical purposes, to review the current scope of levamisole-induced complications in cocaine users and to discuss the pharmacological properties that might explain the motivation behind the large-scale adulteration of cocaine with levamisole. Literature review revealed that significant complications were quickly reported when levamisole was used in inflammatory conditions. By 1976, several cases of leukopenia and agranulocytosis were reported. Recurrence with re-exposure was well described and agranulocytosis spontaneously reversed upon discontinuation of therapy. Vasculitis secondary to levamisole treatment was first reported in 1978 and mostly manifests as leukocytoclastic vasculitis, cutaneous necrotising vasculitis and thrombotic vasculopathy without vasculitis. These findings typically, but not invariably, involve the ear lobes. Discontinuation of levamisole therapy was again a critical part of the treatment. Various neurological side effects were described with levamisole therapy, the most concerning complication being multifocal inflammatory leukoencephalopathy (MIL). Literature review identified 203 unique cases of complications in cocaine users that can be attributed to levamisole adulteration. The two principal complications reported are haematological (140 cases of neutropenia) and dermatological (84 cases). Even though these complications can occur in isolation, many cases displayed both simultaneously. No formal case of leukoencephalopathy in the setting of cocaine use has been reported so far. A striking phenomenon is the apparent high level of recurrence (27.1%) of symptoms in cocaine users after re-exposure to cocaine that is presumably adulterated. The importance of accurately identifying levamisole-induced complications is therefore critical for symptomatic patients as discontinuation of exposure is fundamental and as a correct diagnosis prevents unnecessary and potentially dangerous use of other treatment modalities like powerful immunosuppressive therapy. Literature review suggests that levamisole might have the advantages of enhancing noradrenergic neurotransmission by inhibiting reuptake, by inhibiting MAO and/or COMT, by acting on ganglionic nicotinic receptors and by being partially metabolized into an amphetamine-like compound. It could also increase endogenous opioids and increase dopamine concentration in the cerebral reward pathway. These potential effects make levamisole an interesting choice as a cocaine adulterant. It seems unlikely that levamisole use as a cocaine adulterant will soon reach an end. More information is needed about the diagnosis and treatment of levamisole-induced complications, and the efforts of the medical and public health community is needed to face this challenging problem.
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Affiliation(s)
- Alexandre Larocque
- Emergency Medicine Department, Centre Hospitalier de l'Université de Montréal, Clinical Toxicology Service, McGill University Health Center, Centre Antipoison du Québec, Montreal, Quebec, Canada.
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Feldmann JL, Mery C, Amor B, Kahan A, de Gery A, Delbarre F. Effectiveness of Levamisole in Rheumatoid Arthritis: Immune Changes and Long-Term Results. Scand J Rheumatol 2009. [DOI: 10.1080/03009748109095263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Considerable evidence suggests a role of abnormal T-cell lymphocyte functions in the pathogenesis of minimal lesion nephrotic syndrome. The mean +/- SD T-cell lymphocytes as determined by %E-rosettes among 10 children after 24 to 84 months of complete remission was 66.7 +/- 4.5; this is statistically different from that of seven children with minimal lesion nephrotic syndrome during relapse, 33.5 +/- 9.5 (P less than 0.01). After levamisole therapy at 1.5 to 3.9 mg/kg/dose twice weekly for one to six months, the mean +/- SD %E-rosettes in the latter group was 69.3 +/- 3.9, which is not statistically different from that in the group with complete remission after conventional treatment with steroids. Those treated with levamisole also had a complete remission without any side effects.
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Ullman S, Høier-Madsen M, Halberg P, Jans H, Sylvest J. Deposits of immunoglobulins and complement in skin of patients with rheumatoid arthritis. Influence of anti-rheumatic treatment. Scand J Rheumatol 1979; 8:119-23. [PMID: 377474 DOI: 10.3109/03009747909105349] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Immunopathological studies on skin biopsies from 88 patients with rheumatoid arthritis showed that one-third of them had deposits of IgM and/or C3 in the walls of small vessels immediately underneath the dermal-epidermal junction. The deposits in the vessel walls which may reflect subclinical immune complex vasculitis could be correlated to the occurrence of IgG-rheumatoid factor in the serum, but not to IgM-rheumatoid factor, other extra-articular manifestations, or to the occurrence of circulating immune complexes demonstrated by the complement consumption test or the thrombocyte aggregation test. Two untreated patients had granular deposits in the dermal-epidermal junction. Five out of 50 patients developed deposits in the dermal-epidermal junction during treatment with levamisole, penicillamine, or azathioprine, as observed by serial skin biopsies.
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