ANCA-associated vasculitis presenting with isolated neurological manifestations in a patient with cocaine abuse: a case report and literature review

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a group of rare conditions predominantly affecting small vessels of skin, musculoskeletal, pulmonary, renal, and rarely central and peripheral nervous systems. Isolated neurological manifestations of AAV are uncommon and challenging to diagnose. Cocaine has been reported as a potential trigger for the development of AAV. There are only a few case reports of isolated neurological involvement in cocaine-induced AAV with poorly characterized histopathological features. We present a unique case of AAV with isolated neurological manifestations presenting with multiple cranial neuropathies, leptomeningeal enhancement on imaging and histopathologic evidence of small-vessel vasculitis in the leptomeninges and brain and extensive dural fibrosis in a patient with cocaine abuse. The patient's progressive neurological deficits were controlled after starting immunosuppression with rituximab and prednisone. We also reviewed the literature to provide the diagnostic overview of AAV and evaluate intervention options. To our knowledge, this is the first case of AAV with isolated neurological manifestations and histopathologic evidence of small-vessel vasculitis in a patient with cocaine abuse. Patients with multiple cranial neuropathies and meningeal involvement should be screened for AAV, especially if they have a history of cocaine abuse.

Granulomatosis with polyangiitis or its mimic? A case report

Differentiation between granulomatosis with polyangiitis (GPA) limited to the upper airways and cocaine-induced midline destructive lesion (CIMDL) may be particularly difficult because of their common histopathologic features and antineutrophil cytoplasmic antibody (ANCA) profiles. We herein present a case involving a young woman with an initial diagnosis of GPA based on upper and lower airway manifestations and constitutional symptoms, histopathologic evidence of granulomas, a positive cytoplasmic ANCA indirect immunofluorescent test result, and proteinase 3 positivity by enzyme-linked immunosorbent assay (ELISA). CIMDL was confirmed based on the appearance of a hard palate perforation, positivity for methylecgonine on urine toxicology, a positive perinuclear ANCA indirect immunofluorescent test result, and subsequent human neutrophil elastase (HNE) ANCA positivity by ELISA. Finally, based on the coexistence of CIMDL, constitutional symptoms, and lower airway manifestations, the diagnosis was modified to cocaine-induced GPA mimic. Urine toxicology for cocaine and HNE ELISA are indicated in young patients with GPA who develop limited airway disease to check for the presence of CIMDL and cocaine-/levamisole-induced ANCA-associated vasculitis. Continued abstinence from cocaine is the first-choice therapy for both CIMDL and cocaine-induced GPA mimic.

"Aneurysmal Subarachnoid Hemorrhage and Cocaine Consumption: A Systematic Review and Metanalysis"

BACKGROUND

The use of cocaine can lead to a variety of neurologic complications, including cerebral vasoconstriction, ischemia, aneurysm formation, and aneurysm rupture. A previous study has shown that cocaine use is associated with an increased risk of subarachnoid hemorrhage (SAH). This study conducted a systematic review and meta-analysis of observational studies to assess the association between cocaine use and the risk of poor neurological outcomes and mortality in patients with SAH.

METHODS

A systematic review and meta-analysis were performed following the meta-analysis of observational studies in epidemiology (MOOSE) declaration for systematic reviews and the Cochrane Manual of Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials (RCTs), nonrandomized clinical trials, and prospective and retrospective cohort studies that reported data about adults who suffered Aneurysmal Subarachnoid Hemorrhage (aSAH) after having consumed cocaine recreationally were included. Variables such as mortality, vasospasm, seizures, re-bleeding, and complications were analyzed.

RESULTS

After a thorough selection process, 14 studies involving 116,141 patients, of which 2227 had a history of cocaine consumption, were included in the analysis. There was a significant increase in overall unfavorable outcomes in aSAH patients with a history of cocaine use (OR 5.51 CI 95% [4.26-7.13] P = <0.0001; I2 = 78%), with higher mortality and poor neurologic outcomes. There were no significant differences in the risk of hydrocephalus, seizures, or re-bleeding. Cocaine use was found to increase the risk of vasospasm and overall complications.

CONCLUSIONS

This study insinuates that cocaine use is associated with worse clinical outcomes in aSAH patients. Despite the cocaine users did not exhibit a higher risk of certain complications such as hydrocephalus and seizures, they had an increased risk of vasospasm and overall complications. These findings highlight the importance of addressing the issue of cocaine consumption as a primary preventive measure to decrease the incidence of aSAH and improve patient outcomes.

Prenatal incidence of cleft lip/palate and cocaine abuse in parents: a systematic review and meta-analysis

BACKGROUND

The study aimed to investigate the association between maternal cocaine abuse during pregnancy and the prevalence of cleft lip/palate (CL/P) in offspring, synthesizing existing evidence through a systematic review and meta-analysis. CL/P is a congenital craniofacial anomaly with complex etiology, and prior research has suggested potential links between maternal cocaine use and CL/P. However, these associations remain inconclusive.

METHODS

A comprehensive literature search was conducted to identify relevant studies published up to the study's cutoff date in September 2021. Several databases were systematically searched using predefined search terms. Inclusion criteria were set to encompass studies reporting on the prevalence of CL/P in infants born to mothers with a history of cocaine use during pregnancy, with a comparison group of non-cocaine-using mothers. Data were extracted, and a meta-analysis was performed using a random-effects model to calculate pooled odds ratios (OR) and relative risks (RR) with their respective 95% confidence intervals (CI).

RESULTS

The review included data from 4 studies that met the inclusion criteria. The combined OR from two studies was 0.05 (95% CI: 0.00, 4.41), which does not suggest a statistically significant association between prenatal cocaine exposure and the incidence of CL/P due to the confidence interval crossing the null value. Additionally, the combined RR was 0.17 (95% CI: 0.04, 0.66), indicating a statistically significant decrease in the risk of CL/P associated with prenatal cocaine exposure. These results, with an OR that is not statistically significant and an RR suggesting decreased risk, should be interpreted with caution due to considerable heterogeneity and variability among the included studies' findings. Further research is needed to clarify these associations.

CONCLUSION

The findings from this systematic review and meta-analysis suggest that maternal cocaine use during pregnancy is not a statistically significant independent risk factor for the development of CL/P in offspring. These results underscore the multifactorial nature of CL/P etiology and emphasize the importance of considering other genetic, environmental, and nutritional factors in understanding the condition's origins. While the study provides important insights, limitations such as data heterogeneity and potential confounders should be acknowledged. Future research should adopt rigorous study designs and explore a broader range of potential risk factors to comprehensively elucidate CL/P development.

Imaging of Drug-Related Vasculopathy

Illicit and recreational drugs, such as cocaine, heroin, amphetamines, and marijuana, can result in drug-related vasculitis or vasculopathy. Similarly, the use of certain antithyroid, oncologic, and immunosuppressive medications for therapeutic purposes can lead to vasculopathy. This in turn may result in significant complications in the central nervous system, including intracranial hemorrhage and stroke. Cocaine abuse can also lead to midline destructive lesions of the sinonasal complex. MR imaging, Vessel Wall imaging, and CT/CTA are valuable imaging tools for the evaluation of patients with suspected drug-induced vasculopathy or vasculitis. This article reviews the pathomechanism, clinical presentation, and imaging findings of vasculopathy related to drug abuse and prescribed medications.

Cocaine Gut: A Rare Case of Cocaine-Induced Esophageal, Gastric, and Small Bowel Necrosis

Cocaine is an indirect-acting sympathomimetic drug that inhibits norepinephrine and dopamine reuptake in the adrenergic presynaptic cleft. Cocaine use has been associated with strokes, angina, arrhythmias, and agitation. Data on gastrointestinal complications such as mesenteric ischemia, bowel necrosis, ulceration, and perforation are scarce. Here, we present a rare case of cocaine-induced esophageal, gastric, and small bowel necrosis that contributes to the limited literature on this subject. Diagnosis of cocaine-induced gastrointestinal complications involves a combination of imaging studies, laboratory assessments, and histopathological examinations. Timely surgical resection, supported by intravenous fluids, antibiotics, and pain management, is the mainstay of treatment. The prognosis varies but is significantly influenced by the promptness and effectiveness of the intervention, underscoring the importance of vigilant clinical care in such cases.

Combined use of cocaine and alcohol: A violent cocktail? A systematic review

It is generally believed that the use of alcohol and cocaine alone and especially in combination elicits aggression and violent behaviour. Though there is overwhelming proof that heavy alcohol use is associated with violence, this is not the case for cocaine. Still, in the popular press and by spokesmen of the police, cocaine use is seen as a cause of violent incidents. In the current systematic review, available data from human studies on the relation between cocaine and violent behaviour is presented. In particular, we present scientific data on the acute induction of violence by cocaine alone, as well as, that by the combination of cocaine and alcohol known to be frequently used simultaneously. RESULTS: show that there is only weak scientific evidence for the acute induction of violent behaviour by cocaine, either when used alone or in combination with alcohol. Based on these data we were also able to refute misconceptions about the relation between cocaine and violence published in the popular press and governmental reports, because it appeared that there was hardly any empirical support for this widely shared opinion. Probably, contextual factors, including cocaine use disorder and personality disorder, may better explain the assumed association between cocaine and violence.

Cocaine use in trauma: the vices-paradox revisited

BACKGROUND

The "vices-paradox" describes the paradoxical association between illicit substance use and decreased mortality risk in trauma patients. Cocaine's vasoconstrictive effects may decrease hemorrhage but also increase the risk of thromboembolic complications. To clarify the effects of cocaine use on trauma patients, we compared the risk of mortality and thromboembolic complications in patients screening positive for cocaine with those screening negative.

METHODS

We searched the Trauma Quality Improvement Program database to identify patients 18 years and over who had presented with a drug and alcohol screen on admission between 2017 and 2019. After excluding all patients who had tested positive for alcohol and substances other than cocaine, we then compared the clinical outcomes of patients who were positive and negative for cocaine use.

RESULTS

Of the 312,553 patients identified, 11,942 (3.82%) had tested positive for cocaine. Cocaine users were significantly more likely to present with stab (8.0% vs 3.1%) or gunshot wounds (8.0% vs 3.0%) but had lower rates of mortality (3.6% vs 4.7%), myocardial infarction (0.1% vs 0.2%,) and cerebrovascular accident (0.3% vs 0.4%,). After controlling for covariates, the risk of death, myocardial infarction, and cerebrovascular accident did not significantly differ between cocaine and non-cocaine users.

CONCLUSION

Trauma patients positive for cocaine have similar risks of death and thromboembolic complications and so have a similar prognosis to patients negative for all drugs or alcohol, indicating that the "vices-paradox" does not apply to cocaine use. However, these patients more commonly present after penetrating trauma, suggesting cocaine use in hazardous environments.

Cocaine Use is Associated With Increased LVMI in Unstably Housed Women With Polysubstance Use

BACKGROUND

While substance use is known to influence cardiovascular health, most prior studies only consider one substance at a time. We examined associations between the concurrent use of multiple substances and left ventricular mass index (LVMI) in unhoused and unstably housed women.

METHODS

Between 2016 and 2019, we conducted a cohort study of unstably housed women in which measurements included an interview, serum/urine collection, vital sign assessment, and a single transthoracic echocardiogram at baseline. We evaluated independent associations between 39 separate substances confirmed through toxicology and echocardiography-confirmed LVMI.

RESULTS

The study included 194 participants with a median age of 53.5 years and a high proportion of women of color (72.6%). Toxicology-confirmed substance use included: 69.1% nicotine, 56.2% cocaine, 28.9% methamphetamines, 28.9% alcohol, 23.2% opioid analgesics, and 9.8% opioids with catecholaminergic effects. In adjusted analysis, cocaine was independently associated with higher LVMI (Adjusted linear effect: 18%; 95% CI 9.9, 26.6). Associations with other substances did not reach levels of significance and did not significantly interact with cocaine.

CONCLUSION

In a population of vulnerable women where the use of multiple substances is common, cocaine stands out as having particularly detrimental influences on cardiac structure. Blood pressure did not attenuate the association appreciably, suggesting direct effects of cocaine on LVMI. Routinely evaluating stimulant use as a chronic risk factor during risk assessment and preventive clinical care planning may reduce end organ damage, particularly in highly vulnerable women.

Unusual Tachycardia After Cocaine Use

This case report presents the electrocardiogram findings of a patient in their 20s with severe midsternal chest pain of several hours’ duration after cocaine use.

Concomitant Drug Use among Opioid-Dependent Patients with and without Attention Deficit Hyperactivity Disorder: Does Methylphenidate Merit a Trial?

INTRODUCTION

Concomitant drug use is common among opioid-dependent patients in maintenance therapy. Attention deficit hyperactivity disorder (ADHD), a common comorbidity among opioid users, is associated with a higher risk of concomitant drug use. Earlier studies showed that methylphenidate (MPH) can reduce cocaine consumption among patients with ADHD. The use of MPH as an agonist-replacement or maintenance therapy in cocaine-dependent patients without ADHD is also common in Switzerland, despite a lack of supporting evidence. The aim of this study was to assess concomitant cocaine, amphetamine, MDMA, MPH, and heroin use among patients in opioid maintenance therapy either with or without comorbid ADHD. We expected stimulant consumption to be higher in patients with cocaine dependence and comorbid ADHD and that use of MPH would not lead to a reduction in cocaine consumption in patients without ADHD. We therefore evaluated correlations between use of MPH and cocaine consumption and between MPH consumption and cocaine craving within the two groups.

METHODS

This cross-sectional study included 94 opioid-dependent patients in maintenance therapy in an outpatient department of the Psychiatric Hospital of Zurich. The patients were divided into two groups based on comorbid ADHD; a group with ADHD (N = 27) and a group without ADHD (N = 67). Drug use was assessed using 3-month hair analysis.

RESULTS

We did not find significant differences in the number of patients using cocaine, amphetamine, MDMA, or heroin between groups with or without ADHD. With respect to cocaine use, 85.2 percent of patients in the ADHD group and 73.1 percent in the non-ADHD group were users. The non-ADHD group showed a significant positive correlation between the concentration of MPH and cocaine in hair samples (p < 0.05), and a positive correlation between cocaine craving and the concentration of MPH in hair samples (p = 0.065). These two trends were not evident in the ADHD group.

CONCLUSION

Among patients without ADHD, use of MPH correlates with higher cocaine consumption and craving. Conversely, no significant correlation was found between MPH and cocaine use in patients with ADHD. Our study adds to the evidence that MPH confers negative effects in cocaine users without ADHD and should thus have no place in the treatment of these patients.

Cocaine Use Presenting as Concomitant Myocardial Infraction and Transient Ischemic Attack - A Case Report

Cocaine abuse with its complications is a common problem that presents often in the emergency room. Complications of cocaine use can involve multiple systems. These complications can arise within each system simultaneously or at different times. We treated a patient who presented with symptoms of cerebrovascular accident and was found to have concomitant non-ST segment elevation myocardial infarction (NSTEMI). A 54-year-old male with medical history significant for hypertension and prior MI presented to emergency department with left leg and arm numbness first noticed when he woke up in the morning of presentation. He admitted using cocaine the night prior to presentation. Neurological exam was remarkable for decreased sensation to left extremities. His National Institute of Health Stroke Scale (NHISS) score was 1. Blood work was significant for an elevated troponin I of 1.74 ng/ml, and an elevated Creatinine of 2.34 mg/dl. CT head and MRI brain were negative for acute intracranial hemorrhage or radiological evidence of stroke. He was treated with aspirin, clopidogrel, statin and therapeutic enoxaparin for NSTEMI. His symptoms of left sided numbness resolved over the course of his stay. This case underscores why cocaine abuse should always be considered in the differential for patients presenting with symptoms suggestive of acute coronary syndrome or stroke, especially in young and middle-aged males.

Cortico-striatal networking deficits associated with advanced HIV disease and cocaine use

Cocaine use is disproportionately prevalent in people with HIV (PWH) and is known to potentiate HIV neuropathogenesis. As both HIV and cocaine have well-documented cortico-striatal effects, PWH who use cocaine and have a history of immunosuppression may exhibit greater FC deficits compared to PWH without these conditions. However, research investigating the legacy effects of HIV immunosuppression (i.e., a history of AIDS) on cortico-striatal functional connectivity (FC) in adults with and without cocaine use is sparse. Resting-state functional magnetic resonance imaging (fMRI) and neuropsychological assessment data from 273 adults were analyzed to examine FC in relation to HIV disease: HIV-negative (n = 104), HIV-positive with nadir CD4 ≥ 200 (n = 96), HIV-positive with nadir CD4 < 200 (AIDS; n = 73), and cocaine use (83 COC and 190 NON). Using independent component analysis/dual regression, FC was assessed between the basal ganglia network (BGN) and five cortical networks: dorsal attention network (DAN), default mode network, left executive network, right executive network, and salience network. There were significant interaction effects such that AIDS-related BGN-DAN FC deficits emerged in COC but not in NON participants. Independent of HIV, cocaine effects emerged in FC between the BGN and executive networks. Disruption of BGN-DAN FC in AIDS/COC participants is consistent with cocaine potentiation of neuro-inflammation and may be indicative of legacy HIV immunosuppressive effects. The current study bolsters previous findings linking HIV and cocaine use with cortico-striatal networking deficits. Future research should consider the effects of the duration of HIV immunosuppression and early treatment initiation.

A Case of Chronic Intranasal Cocaine Abuse Masquerading and Exacerbating Underlying Orbital IgG4-Related Disease

Chronic cocaine use may lead to widespread intranasal inflammation and necrosis. Cases of cocaine use affecting the orbit have been reported in the literature with a clinical spectrum ranging from inflammation-induced p-anti-cytoplasmic neutrophil autoantibodies positive vasculitis to severe midline destructive lesions resulting in orbital apex syndrome. Here, we present a case of chronic intranasal cocaine abuse with midline destruction that initially obscured diagnosis of, and is hypothesized to have exacerbated, underlying IgG4-Related Disease (IgG4-RD) of the orbit over a 2-year period.

Cocaine use associated gut permeability and microbial translocation in people living with HIV in the Miami Adult Study on HIV (MASH) cohort

OBJECTIVE

Determine if cocaine use impacts gut permeability, promotes microbial translocation and immune activation in people living with HIV (PLWH) using effective antiretroviral therapy (ART).

METHODS

Cross-sectional analysis of 100 PLWH (ART ≥6 months, HIV-RNA <200 copies/mL) from the Miami Adult Studies on HIV (MASH) cohort. Cocaine use was assessed by self-report, urine screen, and blood benzoylecgonine (BE). Blood samples were collected to assess gut permeability (intestinal fatty acid-binding protein, I-FABP), microbial translocation (lipopolysaccharide, LPS), immune activation (sCD14, sCD27, and sCD163) and markers of inflammation (hs-CRP, TNF-α and IL-6). Multiple linear regression models were used to analyze the relationships of cocaine use.

RESULTS

A total of 37 cocaine users and 63 cocaine non-users were evaluated. Cocaine users had higher levels of I-FABP (7.92±0.35 vs. 7.69±0.56 pg/mL, P = 0.029) and LPS (0.76±0.24 vs. 0.54±0.27 EU/mL, P<0.001) than cocaine non-users. Cocaine use was also associated with the levels of LPS (P<0.001), I-FABP (P = 0.033), and sCD163 (P = 0.010) after adjusting for covariates. Cocaine users had 5.15 times higher odds to exhibit higher LPS levels than non-users (OR: 5.15 95% CI: 1.89-13.9; P<0.001). Blood levels of BE were directly correlated with LPS (rho = 0.276, P = 0.028), sCD14 (rho = 0.274, P = 0.031), and sCD163 (rho = 0.250, P = 0.049).

CONCLUSIONS

Cocaine use was associated with markers of gut permeability, microbial translocation, and immune activation in virally suppressed PLWH. Mitigation of cocaine use may prevent further gastrointestinal damage and immune activation in PLWH.

Crack cocaine use frequency is associated with HIV disease severity independent of antiretroviral therapy exposure: a prospective cohort study

We sought to evaluate the effect of crack cocaine use frequency on HIV disease severity among HIV-positive people who use unregulated drugs (PWUD). We analyzed data from the ACCESS study, an open prospective cohort of HIV-positive PWUD including comprehensive HIV clinical monitoring in a setting with no-cost healthcare. Multivariable generalized linear mixed-effects models were used to estimate the independent effect of time-updated crack cocaine use frequency on HIV disease severity, adjusting for ART exposure and relevant confounders. In multivariable adjusted models, daily or greater frequency of crack cocaine use was significantly associated with higher VACS Index scores (β = 0.8, 95% confidence interval: 0.1, 1.5) as compared to none. Our finding suggests that daily or greater frequency of crack cocaine use exacerbates HIV disease severity independent of ART exposure. The observed effect may reflect an underlying biological mechanism or other factors linked with crack cocaine use; further investigation is warranted.

Occurrence and severity of cocaine-induced hallucinations: Two distinct phenotypes with shared clinical factors but specific genetic risk factors

Cocaine-induced transient hallucinations (CIH) are a frequent complication following cocaine intake that is associated with addiction severity.

METHODS

Two hundred and forty-two non-psychotic and Caucasian lifetime cocaine users were included in a French multicentric study. Clinical variables and dopamine pathway genotype data were extracted and tested with CIH scores using a zero-inflated binomial model, which allows for the exploration of factors associated with occurrence and severity separately.

RESULTS

Cocaine dependence (p_occurrence= 6.18 × 10^-5, p_severity= 9.25 × 10^-8), number of cocaine dependence DSM IV-Tr criteria (p_occurrence= 1.22 × 10^-7, p_severity= 5.09 × 10^-6), and frequency of intake during the worst period of misuse (p_occurrence= 8.51 × 10^-04, p_severity= 0.04) were associated with greater occurrence and higher severity of CIH. The genetic associations did not yield significant results after correction for multiple tests. However, some nominal associations of SNPs mapped to the VMAT2, DBH, DRD1, and DRD2 genes were significant. In the multivariate model, the significant variables were the number of cocaine dependence criteria, lifetime alcohol dependence, and the nominally associated SNPs.

CONCLUSION

Our study shows that CIH occurrence and severity are two distinct phenotypes, with shared clinical risk factors; however, they likely do not share the same genetic background.

Oro-Naso-Sino-Orbital-Cutaneous Fistula From Prolonged Cocaine Use

Presentation We present the case of a 48-year-old man with nasal cellulitis and subsequent oro-naso-sino-orbital-cutaneous fistula from prolonged cocaine use. Diagnosis Initial laboratory investigations reported a raised white cell count (WBC) and C-Reactive Protein (CRP) and subsequently a positive atypical anti-neutrophil cytoplasm antibodies (ANCA) and positive anti-proteinase (PR3). Perihilar lung nodularity on chest imaging raised the possibility of a systemic autoimmune response. His urinalysis was positive for cocaine. Treatment He was commenced on Augmentin, Amphotericin B and Prednisolone. An obturator was created to manage the oro-nasal fistula. A subsequent naso-cutaneous defect was re-approximated. Daily nasal saline douche and abstinence of cocaine were recommended. Discussion Cocaine use in the community is rising and poses a challenge to multiple facets of our health care system.

Smoke Gets in the Eye: A systematic review of case reports of ocular complications of crack cocaine use

ISSUES

Use of crack cocaine and associated medical complications persists globally. Some reports in medical literature describe a sight-threatening condition commonly referred to as 'crack eye' or 'crack eye syndrome'. The purpose of this review is to describe what is known about crack eye from case reports in peer-reviewed literature.

APPROACH

A structured search was completed in MEDLINE, TOXLINE, EMBASE, PsychInfo, Scopus and Biomed Central, to collect case reports and case series on corneal complications attributed to crack cocaine smoking.

KEY FINDINGS

Of 111 articles screened, 11 contained case reports or series. Thirty individual cases of 'crack eye' were reported. The majority (63%) of cases had bilateral involvement; 83% of all cases with microbial culture results had corneal infections. Aggressive treatment caused an improvement in 95% of all cases and 23% of all cases were lost to follow up. Of those who received treatment for corneal complications associated with crack cocaine, 22% remained with significant visual impairment (hand motions only) in the affected eye.

IMPLICATIONS

Clinicians should consider crack cocaine involvement in patients presenting with corneal disease without known predisposing factors, and elicit comprehensive drug histories to prevent a reduction in visual acuity.

CONCLUSION

Corneal complications of crack cocaine smoking are caused by a number of synergistic factors, including direct toxicity of crack cocaine vapours to surface cells, impairment of neurogenic support to corneal epithelial integrity, desiccation of the eye surface due to diminished blinking reflex, low level chemical burns and mechanical denudement of surface cells through eye rubbing.

[Cocaine-induced asthma exacerbation]

Asthma is one of the most common chronic diseases in children and adults. Cocaine is associated with asthma exacerbations. In Denmark, the prevalence of cocaine use has been increasing in recent years. This is a case report of a 47-year-old male with acute asthma exacerbation after cocaine use. Cocaine use is probably an underestimated reason for acute asthma exacerbations.

[Rhabdomyolysis associated with cocaine abuse in a patient with schizophrenia]

Rhabdomyolysis is a syndrome of rapid skeletal muscle breakdown as a result of direct or indirect skeletal muscle injury. An important cause of rhabdomyolysis is the use of hard drugs among which cocaine but also different psychotropic drugs are associated with the development of rhabdomyolysis. The clinical presentation of rhabdomyolysis is diverse and the course can be relatively harmless but also potentially life threatening. Therefore, it is important to recognize rhabdomyolysis in an early stage in order to initiate treatment in a timely manner. We describe a 40-year-old man with schizophrenia who developed rhabdomyolysis after the use of cocaine.

Use of crack cocaine increases tooth loss

PURPOSE

To evaluate the occurrence of tooth loss among crack cocaine users.

METHODS

A cross-sectional study was conducted with 106 crack cocaine users and 106 controls matched for age, gender, and tobacco use. Data were collected on socio-demographic characteristics, drug use, use of dental services, dental caries, periodontal disease, and the outcome (tooth loss).

RESULTS

Crack cocaine users had a greater frequency of tooth loss (55.7% vs. 36.8%), severity of dental caries and periodontal disease and less use of dental services than the controls (P< 0.05). After adjustments, tooth loss was 46% more frequent among crack cocaine users (PR= 1.46; 95%, CI: 1.10-1.93) as well as significantly more frequent among non-whites, those older than 24 years of age and those with high dental caries severity. Occurrence of tooth loss was significantly higher among crack cocaine users. These findings can contribute to the planning and implementation of prevention strategies and oral health care for individuals with a chemical dependence.

CLINICAL SIGNIFICANCE

The use of crack cocaine had a negative impact on the oral health of its users, leading to tooth loss and a greater severity of dental caries. These findings should be considered when planning prevention strategies to improve oral health in individuals addicted to crack cocaine.

Prevalence of myocardial infarction among patients with chest pain and cocaine use: A systematic review and meta-analysis

BACKGROUND

Cocaine abuse is a public health burden. Cocaine is known to cause vasospasm and acute myocardial infarction (AMI). The prevalence of AMI in patients presenting with chest pain and concurrent cocaine use (CPCC) varies among studies. We performed a systemic review and meta-analysis to assess the current literature for the prevalence of AMI in patients with CPCC.

METHODS

We performed a literature search of PubMed, EMBASE, and Scopus from its beginning to May 18, 2020 and updated this search on February 18, 2021. Full-text studies that assessed the primary outcome (AMI) specifically among patients with CPCC who presented to the emergency department (ED) were included. We excluded studies that were not in English, did not take place in the ED, and case reports, which only reported positive cases and not incidence of AMI. Random effect meta-analysis was performed to assess the prevalence of primary outcome and to examine correlations between risk factors and AMI. Heterogeneity was assessed by I-square value. We also performed subgroup analysis to identify potential sources of heterogeneity.

RESULTS

We identified 2178 studies and screened 102 full-text studies to include 16 studies (3269 patients) in our final analysis. The pooled prevalence of AMI was 4.7% (95% CI 0.8-23), I-square of 84%. However, rates among studies of low risk patients were lower (1.1% 95% CI 0.2-5) compared to studies of mixed risk patients (7.7%, 95% 5-11). A meta-regression was used to look at correlation between risk factors and AMI and found that AMI was positively correlated in patients with a history of CAD (correlation coefficient [Corr. Coeff.] 5.6, 96% CI 2.3-8.7), HTN (Corr. Coeff. 2.9, 95% CI 0.9-4.9), DM (Corr. Coeff. 8.0, 95% CI 2.4-14), HLD (Corr. Coeff. 5.9, 95% CI 2.4, 9). Sources of potential heterogeneity included patients' risk as defined by the authors, study designs, publication year, and study sample size.

CONCLUSION

The overall prevalence of AMI and death among patients with cocaine-associated chest pain was relatively low, although high risk patients were still associated with high prevalence of AMI. Clinicians should consider risk-stratify these patients and treat them accordingly.

Effects of cocaine and HIV on decision-making abilities

Our study aimed to understand the impact of cocaine dependence on high-risk decision-making abilities in individuals with the human immunodeficiency virus (HIV) and individuals with cocaine dependence. We recruited 99 participants (27 HIV/Cocaine, 20 HIV Only, 26 Cocaine Only, and 26 Healthy Controls). The Iowa Gambling Task (IGT) was applied to assess decision-making abilities. Independent and interactive effects of HIV status and cocaine dependence were examined using 2 × 2 factorial ANCOVA with premorbid IQ (WRAT-4: WR) as the covariate. We found cocaine dependence had a significant adverse effect on overall IGT performance (p = 0.015). We also found individuals who were HIV-positive tended to have less total money at the end of the game than individuals who were HIV-negative (p = 0.032), suggesting individuals living with HIV had less focus on long-term gains and more focus on short-term gains. Our findings highlight the significant impact of cocaine dependence on decision-making abilities and the difficulty individuals with HIV have in adequately weighing the cost and benefits of their decisions and making appropriate changes for the future.

Cocaine Consumption and Antineutrophil Cytoplasmic Antibody-associated Glomerulonephritis: A Case Report

ABSTRACT

Cocaine is often sold in a mixture with levamisole to increase the profit margin and potentiate the euphoric effect. Apart from an overdose, cocaine can induce a wide range of clinical symptoms. We present a case of cocaine/levamisole-induced pauci-immune glomerulonephritis. A 22-year-old patient was sent to the hospital after a laboratory result showed an unexpected acute kidney injury, with an estimated glomerular filtration rate of 34 mL/min/1.73 m2. The medical history included cocaine abuse. Renal biopsy showed a pauci-immune necrotizing glomerulonephritis. Antineutrophil cytoplasmic antibodies were positive with a perinuclear staining pattern and target specificity for leucocyte myeloperoxidase (antimyeloperoxidase). Despite treatment, the kidney function did not show significant improvement. The forensic implication of this case is that even if the toxicological values are not high enough to suggest a lethal intoxication, an idiosyncratic reaction on cocaine and/or levamisole has to be taken into account.

Pyoderma gangrenosum associated to the use of cocaine/levamisole. Series of three cases and literature review

Pyoderma gangrenosum associated to the use of cocaine/levamisole is a rare condition associated to their consumption. Cocaine use is frequent in Colombia, and the substance is contaminated with levamisole, an anthelmintic that increases the psychotropic effects and enhances its side effects. We present three clinical cases of patients with ulcerated lesions, in which the diagnosis was pyoderma gangrenosum secondary to the use of cocaine contaminated with levamisole. This called the attention of the health staff to investigate the abuse of substances in gangrenous pyoderma and also evidence that the interruption of consumption was the basis of management.

Levamisole-Induced Necrosis and Vasculitis

A 56 year-old Caucasian man with a past medical history (PMH) of cytopenia and a positive antinuclear antibody (ANA) presented to the dermatology office due to painful discoloration of the ears (Figure 1) and a "rash" on the upper portion of his right arm (Figure 2) which had initially subsided but later worsened. Punch biopsies of the right ear and right arm lesions were performed at the initial visit. (SKINmed. 2021;19:-0).

Pyoderma gangrenosum associated with levamisole-adulterated cocaine in a c-ANCA positive patient

Pyoderma gangrenosum (PG) is an inflammatory, ulcerative condition that is characterized by painful ulcers that commonly present on the lower extremities. Up to half of PG cases are associated with underlying systemic disease, including inflammatory bowel disease, various autoimmune conditions, and malignancy. Another well-known association is the manifestation of PG with recreational cocaine use, especially cocaine contaminated with the adulterant agent levamisole. Once utilized for its immunomodulatory capabilities, levamisole was withdrawn from the market in 2002. It has since been repurposed to potentiate the amphetamine-like effects and duration of cocaine and has reduced preparation cost. We present a 52-year-old woman with chronic maxillary sinusitis and cocaine use disorder presenting with a two-week history of painful ulcers on bilateral lower extremities, each with a purulent base and undermined, violaceous borders. Urine toxicology was positive for cocaine and serologic studies were positive for cytoplasmic antineutrophil cytoplasmic antibodies (c-ANCA) and lupus anticoagulant. Underlying conditions, especially that of granulomatosis with polyangiitis, were considered and ultimately ruled out. The patient's lesions exhibited a marked response with a short course of oral corticosteroids, typical of PG associated with levamisole. This case highlights the crucial role that drug abstinence plays in the prevention of recurrence.

Detection of subclinical myocardial dysfunction in cocaine addicts with feature tracking cardiovascular magnetic resonance

BACKGROUND

Cocaine is an addictive, sympathomimetic drug with potentially lethal effects. We have previously shown with cardiovascular magnetic resonance (CMR) the presence of cardiovascular involvement in a significant percentage of consecutive asymptomatic cocaine addicts. CMR with feature-tracking analysis (CMR-FT) allows for the quantification of myocardial deformation which may detect preclinical involvement. Therefore, we aimed to assess the effects of cocaine on the left ventricular myocardium in a group of asymptomatic cocaine users with CMR-FT.

METHODS

In a cohort of asymptomatic cocaine addicts (CA) who had been submitted to CMR at 3 T, we used CMR-FT to measure strain, strain rate and dyssynchrony index in CA with mildly decreased left ventricular ejection fraction (CA-LVEFd) and in CA with preserved ejection fraction (CA-LVEFp). We also measured these parameters in 30 age-matched healthy subjects.

RESULTS

There were no differences according to age. Significant differences were seen in global longitudinal, radial and circumferential strain, in global longitudinal and radial strain rate and in radial and circumferential dyssynchrony index among the groups, with the lowest values in CA-LVEFd and intermediate values in CA-LVEFp. Longitudinal, radial and circumferential strain values were significantly lower in CA-LVEFp with respect to controls.

CONCLUSIONS

CA-LVEFp show decreased systolic strain and strain rate values, with intermediate values between healthy controls and CA-LVEFd. Signs suggestive of dyssynchrony were also detected. In CA, CMR-FT based strain analysis can detect early subclinical myocardial involvement.

Cocaine use in organ donors and long-term outcome after heart transplantation: An International Society for Heart and Lung Transplantation registry analysis

BACKGROUND

Cardiac allografts from donors with a history of cocaine use (DHCU) are often discarded owing to concerns regarding organ quality. We investigated long-term outcomes of de novo adult heart transplantation (HTx) using DHCU.

METHODS

Using the International Society for Heart and Lung Transplantation Thoracic Organ Transplant Registry, we identified 24,430 adult recipients of primary, deceased donor, heart-alone transplants between January 1, 2000, and June 30, 2013. Transplants were categorized on the basis of DHCU. Survival rates were compared using Kaplan-Meier curves and log-rank tests.

RESULTS

A total of 3,246 (13.3%) HTx were performed using DHCU during the study period. Of these, 1,477 (45.5%) were classified as current users. Organs from DHCU were transplanted at a later sequence number (data from a sub-group of patients transplanted in the United States) than those from the non-cocaine use group (mean sequence number 16.1 ± 55.6 vs 11.5 ± 38.2; p < 0.001), suggesting higher decline rates by centers. Kaplan-Meier estimates of survival were not different between groups (p = 0.16), with post-transplant survival rates at 1, 5, and 10 years of 88.1%, 75.8%, and 58.5%, respectively, in the non-cocaine use group and 90.0%, 76.7%, and 59.7%, respectively, in the DHCU group. On multivariate analysis, DHCU were not associated with mortality (hazard ratio [HR]: 0.94; 95% CI: 0.88-1.00; p = 0.050), cardiac allograft vasculopathy (HR: 1.02; 95% CI: 0.94-1.11; p = 0.56), or allograft rejection (HR: 0.98; 95% CI: 0.92-1.05; p = 0.61).

CONCLUSIONS

Our findings demonstrate that adult HTx performed using DHCU is not associated with an adverse impact on long-term clinical outcomes. These findings should spur efforts to reduce discard rates of organs from DHCU.

[Asthma and cannabis, cocaine or heroin use]

INTRODUCTION

The use of cannabis, cocaine or heroin can be responsible for many respiratory complications including asthma.

OBJECTIVES

The aim of this systematic literature review of data was to expose the relations between cannabis, cocaine or heroin use and asthma.

RESULTS

Cannabis, cocaine or heroin use by inhalation may be responsible for respiratory symptoms (cough, wheezing), asthma onset, acute asthma exacerbations (which may require intubation and invasive ventilation) or deaths related to asthma. Lower adherence to asthma treatment is also observed. Cannabis induces a rapid bronchodilator effect. In contrast, its chronic use may induce a decrease in specific airway conductance. Studies on forced expiratory volume in one second (FEV1) reduction or decline are discordant.

CONCLUSION

Cannabis, cocaine or heroin use must be considered in cases of acute respiratory symptoms or asthma exacerbation in young persons and practitioners must help illicit substance users to stop their consumption.

Toxic leukoencephalopathy-When a Boxer's fracture requires an MRI and LP

This case report describes a young patient presenting to the ED with altered mental status several days after being diagnosed with a Boxer's fracture and ultimately discovered to have toxic leukoencephalopathy. We review the clinical features in his presentation leading to his diagnosis, as well as MRI imaging findings frequently found in his condition.

Anabolic-androgenic steroids and brain injury: miRNA evaluation in users compared to cocaine abusers and elderly people

Anabolic-androgenic steroids (AASs) can be used to treat both hormonal diseases and other pathologies characterized by muscle loss (aging, cancer, and AIDS). Even if the adverse effects related to the misuse of AASs have been well studied in different systems and apparatuses, knowledge about brain damage is poor.In this scenario, this experimental study aimed to analyze the role of several microRNAs (miRNAs) in brain damage after AAS misuse, to better comprehend the underlying mechanisms. The research hypothesis at the base of this experimental study is that the chronic use of AASs may be associated to brain damage with a dysregulation of these miRNAs. Moreover, miRNA expression values were compared among three different groups, "AAS" group, "Cocaine" group and "Aging" group, in order to define if AAS brain damage can be compared with the brain impairment linked to aging and/or cocaine assumption.This experimental study revealed that the tested miRNAs (hsa-miR-21-5p, hsa-miR-34a-5p, hsa-miR-124-5p, hsa-miR-132-3p, and hsa-miR-144-3p) were overexpressed in all enrolled groups. In the light of the presented results, the identification of specific circulating and/or tissue biomarkers is challenging for the scientific community. Further studies with larger samples are needed to confirm these interesting findings.

Optical neuropathy due to inhaled cocaine, causality or chance

A 44-year-old man, active cocaine consumer, who referred decrease in visual acuity in the right eye in 24 hours of evolution, being 0,05 in that eye and 1 in the left eye. The examination showed a relative afferent pupil defect and a swelling head of optic nerve. The systemic studies performed were normal, except the nuclear magnetic resonance of the brain that showed a thickening of the maxillary and frontal sinus mucosa, compatible with sinusitis. Hospital admission and the start of intravenous corticosteroid treatment were decided, with a favourable evolution, a visual acuity of 1.0 in both eyes and an anatomical improvement of the optic nerve head. Due to the medical history of the patient and the assessment of other plausible alternative diagnoses, we established the diagnosis of optical neuropathy due to inhaled cocaine abuse.

Risk-taking and fairness among cocaine-dependent patients in dual diagnoses: Schizophrenia and Anti-Social Personality Disorder

This study reports experimental results from a clinical sample of patients with a cocaine-related disorder and dual diagnosis: Schizophrenia and Anti-Social Personality Disorder. Both types of patients as well as a non-clinical group of students performed two incentivized decision-making tasks. In the first part of the experiment, they performed a lottery-choice task in order to elicit their degree of risk aversion. In the second part, they decided in two modified dictator games aimed at eliciting their aversion to advantageous and disadvantageous inequality. It is found that the Anti-Social Personality Disorder group exhibits no significant differences from the non-clinical sample in either task. However, compared with the students' sample, subjects from the group with schizophrenia show more risk aversion and exhibit more aversion towards disadvantageous inequality.

Food insecurity and substance use in people with HIV infection and substance use disorder

BACKGROUND

Food insecurity and substance use are common among people living with HIV (PLWH). Substance use may help people cope with hunger and thus be associated with food insecurity, but the association is uncertain. This study assessed whether, in PLWH and substance dependence, if there was an association between food insecurity and substance use.

Methods: We studied adults with HIV and current substance dependence or ever injection drug use interviewed at 12 and 24 months after enrollment in a prospective cohort study. The presence of food insecurity (insufficient food quantity or quality, or anxiety about its availability) was assessed using the Household Food Insecurity Assessment Scale questionnaire (HFIAS). Unhealthy alcohol use was assessed with the Alcohol Use Disorder Identification Test - Consumption (AUDIT-C) and past 30-day other drug use with the Addiction Severity Index. Associations using repeat cross-sectional data from each of two time-points, 12 months apart, from the same participants were tested using generalized estimating equations logistic regressions.

Results: The 233 participants had a mean age of 50 years and 65% were male. At the first interview, 44% reported food insecurity, 40% unhealthy alcohol use, 25% past 30-day cocaine use, and 17% past 30-day illicit opioid use. In analyses adjusted for demographics, social factors, physical and mental health function, and substance use related variables, there was no significant association between food insecurity and unhealthy alcohol use (adjusted odds ratio (aOR) = 1.06 (95% CI: 0.59, 1.87)). Those with food insecurity had higher odds of illicit opioid use (aOR = 2.5 (95% CI: 1.12, 5.58)) and cocaine use (aOR = 1.95 (CI 95%: 1.00, 3.81)).

Conclusion: Food insecurity was not associated with unhealthy alcohol use but was associated with cocaine and illicit opioid use. Given the prevalence and impact substance use has on PLWH, food insecurity should be identified and addressed.

Pulmonary-renal syndrome secondary to cocaine-levamisole-induced vasculitis: A case report

Pulmonary-renal syndrome has rarely been reported as the clinical presentation of vasculitis caused by the consumption of cocaine adulterated with levamisole. We report the case of a patient in whom we detected the clinical manifestations and indicate the difficulties that arose in relation to the diagnostic and therapeutic approach.

[Febrile agranulocytosis and reactive arthropathy associated with cocaine consumption in an HLA B27 positive patient]

Agranulocytosis associated with cocaine use is a phenomenon linked to the presence of levamisole, an anthelminthic and immunomodulating agent, used as an adulterant to cocaine. This reaction has been associated with the presence of HLA B27. In addition to agranulocytosis, people who use levamisole-adulterated cocaine may develop fever, skin lesions, arthralgias, and less frequently, inflammatory enthesitis and arthritis. We present the case of a cocaine-consuming patient with HLA B27 genotype, who developed febrile agranulocytosis and inflammatory arthropathy. The presence of p ANCA, atypical ANCA and MPO was detected in blood, and other causes of agranulocytosis were excluded. He was treated with corticosteroids and later methotrexate, therapy for addiction, with good evolution.

Cocaine using patient who presents with dyspnoea

We present the case of a 17-year-old male patient with a history of cocaine use who consulted for chest pain and dyspnoea. A pneumomediastinum is defined as the irruption of air in the mediastinal space, and is associated with different causes, including addiction to inhaled drugs. It occurs in people with predisposing factors and the presence of precipitating factors such as consumption of inhaled drugs. X-ray and computed tomography of the thorax are very useful tools in guiding the diagnosis. The low incidence of this pathology represents a difficult diagnosis for the doctor, although in some characteristic work environments a high level of suspicion is necessary.