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Retiform Purpura Caused by the Use of Cocaine, That Was Probably Adulterated with Levamisole

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Letter to the Editor

Vol. 27, No. 1, 2015 117

Received June 24, 2013, Revised January 23, 2014, Accepted for publication April 27, 2014

Corresponding author: Jose Luis Torregrosa Calatayud, Department of Dermatology, General Hospital of Valencia, Avenida Tres Cruces Nº2, Valencia 46014, Spain. Tel: 34-665242548, Fax: 34-963-131-297, E-mail: joseluistorregrosa17@gmail.com

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://

creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, pro- vided the original work is properly cited.

Online J 2011;17:25.

3. López-Cepeda LD, Domínguez-Gómez MA, Novales-Santa CJ, Guarneros-Campos A. Segmental neurofibromatosis of facial localization. Int J Dermatol 2005;44:583-586.

4. Agarwal A, Thappa DM, Jayanthi S, Shivaswamy KN.

Segmental neurofibromatosis of face. Dermatol Online J 2005;11:33.

5. Jankovic I, Kovacevic P, Visnjic M, Jankovic D, Velickovic M. A unique case of hereditary bilateral segmental neuro- fibromatosis on the face. An Bras Dermatol 2012;87:895-898.

http://dx.doi.org/10.5021/ad.2015.27.1.117

Retiform Purpura Caused by the Use of Cocaine, That Was Probably Adulterated with Levamisole

Jose Luis Torregrosa Calatayud, Juan Garcías Ladaria, Blanca De Unamuno Bustos, Violeta Zaragoza Ninet, Victor Alegre De Miquel

Department of Dermatology, General Hospital of Valencia, Valencia, Spain

Dear Editor:

Retiform purpura is a dermatological condition charac- terized by reticulated, stellate, or serpentine shaped pur- ple lesions on the skin and mucous membranes. New, multiple cases of retiform purpura after the use of levami- sole adulterated cocaine have been reported. Levamisole is an anthelmintic drug with immunomodulatory and im- munostimulating properties. It has been used in humans to treat rheumatoid arthritis, cancer of the colon and neph- ritic syndrome in children. It was withdrawn from use in the United States in 2000 because of the risk of agranulo- cytosis1.

We report the case of a 52-year-old woman receiving treatment with levothyroxine for hypothyroidism. Two days after consuming cocaine, she developed painful skin lesions with arthralgia on both wrists. Physical examina- tion revealed plaques and papules infiltrated to touch, pur- puric on the edges and necrotic in the center, with retic- ular and stellate lesions on both cheeks, the tip of the

nose, outer left ear, and lower limbs (Fig. 1). Biopsy re- vealed thrombotic vasculopathy of the small and medium blood vessels in the dermis and subcutaneous cell tissue (Fig. 2). Blood tests revealed leukopenia, neutropenia, and lymphopenia. Antinuclear antibodies (ANA, titer 1 : 1.280) in anti-neutrophil cytoplasm antibodies (ANCAs) against myeloperoxidase with a p-ANCA pattern (titer, >100 [0∼

5]), and ANCAs against proteinase 3 with a c-ANCA pat- tern (titer, 6.8 [0∼5]) were also found. Hypocomplemen- temia of C3 was detected. The tests for thrombosis and co- agulation, serology, cryoglobulins and antiphospholipid antibodies were normal or negative. Cocaine was detected in the urine sample. The results of chest radiography and urine sediment test were normal. A diagnosis of retiform purpura resulting from the use of cocaine, that was prob- ably adulterated with levamisole was made. She was pre- scribed with low dose oral prednisone. The hematological symptoms cleared 5 days later, after one month, the skin lesions had healed without sequelae.

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Letter to the Editor

118 Ann Dermatol

Fig. 2. Hematoxylin-eosin staining image (×10) showing thrombotic vasculopathy of the small and medium blood vessels in the dermis and subcutaneous cell tissue.

Fig. 1. (A) A reticular plaque with purpuric edges and necrotic center on the left cheek. (B) Reticular and stellate plaques with purpuric edges and necrotic center on low limbs.

Levamisole is currently only used in veterinary medicine as an anthelmintic; however, it has recently begun to be used as an adulterant in cocaine in many countries, in- cluding Spain2. Levamisole poisoning should be suspected in the case of a young patient presenting bilateral cuta- neous necrosis on the earlobes, cheeks, or nose, that may be accompanied with retiform purpura lesions, primarily on the legs3. There may also be signs of arthralgia, fatigue, and general malaise. In the literature, some cases showing convulsions, kidney failure, or pulmonary haemorrhage have also been reported. The most common alterations in

laboratory tests are neutropenia, a p-ANCA pattern, and the presence of antiphospholipid antibodies. More specific immune markers include antielastase antibodies. However, to confirm the diagnosis, levamisole detection in urine by using gas chromatography-mass spectrometry is required.

However, most of the reported cases, including ours, are unconfirmed. This is because of the unavailability of test- ing techniques4 and the short half-life of levamisole (5.5∼

6 h)5. Two histological patterns have been documented:

leukocytoclastic vasculitis and thrombotic vasculopathy.

In most patients, skin lesions resolve spontaneously 2∼3 weeks after stopping levamisole. However, the serological alterations may persist for up to 14 months3.

REFERENCES

1. Lee KC, Ladizinski B, Federman DG. Complications associ- ated with use of levamisole-contaminated cocaine: an emer- ging public health challenge. Mayo Clin Proc 2012;87:

581-586.

2. Ventura Vilamala M, Caudevilla Gálligo F, Vidal Giné C;

Grupo Investigadores SELECTO. Levamisole-adulterated co- caine: potential clinical implications. Med Clin (Barc) 2011;

136:367-368.

3. Rongioletti F, Ghio L, Ginevri F, Bleidl D, Rinaldi S, Edefonti A, et al. Purpura of the ears: a distinctive vasculopathy with circulating autoantibodies complicating long- term treatment with levamisole in children. Br J Dermatol 1999;140:948- 951.

4. Lynch KL, Dominy SS, Graf J, Kral AH. Detection of leva- misole exposure in cocaine users by liquid chromatography- tandem mass spectrometry. J Anal Toxicol 2011;35:176-178.

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Letter to the Editor

Vol. 27, No. 1, 2015 119

Received November 6, 2013, Revised April 21, 2014, Accepted for publication April 27, 2014

Corresponding author: Woo-Young Sim, Department of Dermatology, Kyung Hee University Hospital at Gangdong, 892 Dongnam-ro, Gangdong-gu, Seoul 134-727, Korea. Tel: 82-2-440-7335, Fax: 82-2-440-7336, E-mail: sim@khnmc.or.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://

creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Fig. 1. (A, B) Hair thinning and a decreased hair density is observed symmetrically along the frontal and bitemporal incision lines.

(C) Increased numbers of telogen hair follicles are found, and peribulbar inflammation, scarring, and hair shaft abnormality are not observed on the scalp biopsy (H&E, ×100; transverse section).

5. de la Hera I, Sanz V, Cullen D, Chico R, Petiti G, Villar M, et al. Necrosis of ears after use of cocaine probably adulte-

rated with levamisole. Dermatology 2011;223:25-28.

http://dx.doi.org/10.5021/ad.2015.27.1.119

Localized Telogen Effluvium after Face Lift Surgery

Jung-Hee Kim, Bark-Lynn Lew, Woo-Young Sim

Department of Dermatology, Kyung Hee University School of Medicine, Seoul, Korea

Dear Editor:

A 62-year-old woman presented at Kyung Hee University Hospital at Gangdong with a 2-month history of frontal and bitemporal shedding and thinning. Two months prior to visiting our clinic, she had undergone rhytidectomy at a local plastic surgery clinic. Her past medical history was not significant. There was no drug history, weight change, or chronic illness, and the patient denied any other trauma history. The physical examination revealed symmetric frontal and bitemporal thinning and decreased hair density (Fig. 1A, B). In a hair pull test, ≥10 hairs were easily pulled from around the suture line of the rhytidectomy;

however, the hair pull test was negative in other parts of the scalp. On transverse sections of a 5-mm punch biopsy specimen, normal follicular density and increased num- bers of telogen hair follicles were observed. Peribulbar in- flammation, scarring, and hair shaft abnormality were not observed (Fig. 1C). On the basis of the clinical and histo- pathologic findings, she was diagnosed with telogen efflu- vium, which occurred after rhytidectomy. Without any treatment, the patient noted the natural recovery of hair shedding, and the regrowth of many hairs was observed around the affected areas 4 months after rhytidectomy (Fig. 2).

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Fig. 2. Hematoxylin-eosin staining image (×10) showing  thrombotic vasculopathy of the small and medium blood vessels  in the dermis and subcutaneous cell tissue.
Fig. 1. (A, B) Hair thinning and a decreased hair density is observed symmetrically along the frontal and bitemporal incision lines

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