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A case series and literature review on patients with rhinological complications secondary to the use of cocaine and levamisole

  • R J Green (a1), Q Gardiner (a1), K Vinod (a2), R Oparka (a3) and P D Ross (a1)...

Abstract

Background

Levamisole is an increasingly common cutting agent used with cocaine. Both cocaine and levamisole can have local and systemic effects on patients.

Methods

A retrospective case series was conducted of patients with a cocaine-induced midline destructive lesion or levamisole-induced vasculitis, who presented to a Dundee hospital or the practice of a single surgeon in Paisley, from April 2016 to April 2019. A literature review on the topic was also carried out.

Results

Nine patients from the two centres were identified. One patient appeared to have levamisole-induced vasculitis, with raised proteinase 3, perinuclear antineutrophil cytoplasmic antibodies positivity and arthralgia which improved on systemic steroids. The other eight patients had features of a cocaine-induced midline destructive lesion.

Conclusion

As the use of cocaine increases, ENT surgeons will see more of the complications associated with it. This paper highlights some of the diagnostic issues and proposes a management strategy as a guide to this complex patient group. Often, multidisciplinary management is needed.

Copyright

Corresponding author

Author for correspondence: Mr Richard James Green, ENT Department, Ninewells Hospital, DundeeDD1 9SY, Scotland, UK E-mail: Richard.green14@nhs.net Fax: +44 (0)1382 632816

Footnotes

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Mr R J Green takes responsibility for the integrity of the content of the paper

Footnotes

References

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1Chung, C, Tumeh, PC, Birnbaum, R, Tan, BH, Sharp, L, McCoy, E et al. Characteristic purpura of the ears, vasculitis, and neutropenia– a potential public health epidemic associated with levamisole-adulterated cocaine. J Am Acad Dermatol 2011;65:722–510.1016/j.jaad.2010.08.024
2Barbano, G, Ginevri, F, Ghiggeri, GM, Gusmano, R. Disseminated autoimmune disease during levamisole treatment of nephrotic syndrome. Pediatr Nephrol 1999;13:602–310.1007/s004670050753
3Nolan, L, Jen, KY. Pathologic manifestations of levamisole-adulterated cocaine exposure. Diagn Pathol 2015;10:48
4United Nations Office on Drugs and Crime. World Drug Report 2016. Vienna: United Nations Office on Drugs and Crime, 2016
5Scottish Government. Scottish Crime and Justice Survey 2014/15: Drug Use. In: https://www.gov.scot/publications/scottish-crime-justice-survey-2014-15-drug-use/ [12 April 2020]
6Morassi, ML, Trimarchi, M, Nicolai, P, Gregorini, G, Maroldi, R, Specks, U et al. Cocaine, ANCA, and Wegener's granulomatosis. Pathologica 2001;93:581–3
7Bradford, M, Rosenberg, B, Moreno, J, Dumyati, G. Bilateral necrosis of earlobes and cheeks: another complication of cocaine contaminated with levamisole. Ann Intern Med 2010;152:758–910.7326/0003-4819-152-11-201006010-00026
8Kunzler, D, Lagrimas, L, Vo, T, DeCrescenzo, A, Kaltwasser, K, Wilson, J. Antineutrophil cytoplasmic antibodies negative levamisole-induced leukocytoclastic vasculitis: a presumed case and literature review. Int J Dermatol 2018;57:1411–16
9Lood, C, Hughes, G. Neutrophil extracellular traps as a potential source of autoantigen in cocaine-associated autoimmunity. Rheumatology (Oxford) 2017;56:638–43
10Trimarchi, M, Bussi, M, Sinico, RA, Meroni, P, Specks, U. Cocaine-induced midline destructive lesions – an autoimmune disease? Autoimmun Rev 2013;12:496500
11Trimarchi, M, Gregorini, G, Facchetti, F, Morassi, ML, Manfredini, C, Maroldi, R et al. Cocaine-induced midline destructive lesions: clinical, radiographic, histopathologic, and serologic features and their differentiation from Wegener granulomatosis. Medicine (Baltimore) 2001;80:391404
12Wiesner, O, Russell, KA, Lee, AS, Jenne, DE, Trimarchi, M, Gregorini, G et al. Antineutrophil cytoplasmic antibodies reacting with human neutrophil elastase as a diagnostic marker for cocaine-induced midline destructive lesions but not autoimmune vasculitis. Arthritis Rheum 2004;50:2954–65
13Subesinghe, S, van Leuven, S, Yalakki, L, Sangle, S, D'Cruz, D. Cocaine and ANCA associated vasculitis-like syndromes – a case series. Autoimmun Rev 2018;17:73–710.1016/j.autrev.2017.11.011
14McGrath, MM, Isakova, T, Rennke, HG, Mottola, AM, Laliberte, KA, Niles, J. Contaminated cocaine and antineutrophil cytoplasmic antibody-associated disease. J Am Soc Nephrol 2011;6:2799–805
15Pearson, T, Bremmer, M, Cohen, J, Driscoll, M. Vasculopathy related to cocaine adulterated with levamisole: a review of the literature. Dermatol Online J 2012;18:1
16Marquez, J, Aguirre, L, Muñoz, C, Echeverri, A, Restrepo, M, Pinto, LF. Cocaine-levamisole-induced vasculitis/vasculopathy syndrome. Curr Rheumatol Rep 2017;19:36
17Czuchlewski, DR, Brackney, M, Ewers, C, Manna, J, Fekrazad, MH, Martinez, A et al. Clinicopathologic features of agranulocytosis in the setting of levamisole-tainted cocaine. Am J Clin Pathol 2010;133:466–72
18Abdul-Karim, R, Ryan, C, Rangel, C, Emmett, M. Levamisole-induced vasculitis. Proc (Bayl Univ Med Cent) 2013;26:163–5
19Trimarchi, M, Nicolai, P, Lombardi, D, Facchetti, F, Morassi, ML, Maroldi, R. Sinonasal osteocartilaginous necrosis in cocaine abusers: experience in 25 patients. Am J Rhinol 2003;17:3343
20Trimarchi, M, Bondi, S, Della Torre, E, Terreni, MR, Bussi, M. Palate perforation differentiates cocaine-induced midline destructive lesions from granulomatosis with polyangiitis. Acta Otorhinolaryngol Ital 2017;37:281–5
21Peikert, T, Finkielman, JD, Hummel, AM, McKenney, ME, Gregorini, G, Trimarchi, M et al. Functional characterization of antineutrophil cytoplasmic antibodies in patients with cocaine-induced midline destructive lesions. Arthritis Rheum 2008;58:4651
22Roberts, JA, Chevez-Barrios, P. Levamisole-induced vasculitis: a characteristic cutaneous vasculitis associated with levamisole adulterated cocaine. Arch Pathol Lab Med 2015;139:1058–61
23Molteni, M, Saibene, AM, Luciano, K, Maccari, A. Snorting the clivus away: an extreme case of cocaine-induced midline destructive lesion. BMJ Case Rep 2016;2016:bcr2016216393
24Pope, JD, Drummer, OH, Schneider, HG. The cocaine cutting agent levamisole is frequently detected in cocaine users. Pathology 2018;50:536–9
25Imbernón-Moya, A, Chico, R, Aguilar-Martínez, A. Cutaneous mucosal manifestations associated with cocaine use [in Spanish]. Med Clin (Barc) 2016;146:544–910.1016/j.medcli.2016.02.015

Keywords

A case series and literature review on patients with rhinological complications secondary to the use of cocaine and levamisole

  • R J Green (a1), Q Gardiner (a1), K Vinod (a2), R Oparka (a3) and P D Ross (a1)...

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