A 50‐year‐old male presented with two days of left lower back pain, vomiting, and dark urine. He described the pain as dull, persistent and extending from the left lower back to the upper and lower quadrants of his abdomen. Along with a history of hematuria and joint pains, he also endorsed a reddish rash for the past year. No tenderness was noted in any quadrant on abdominal exam nor was it noted on the flanks. His creatinine was 5 mg/dL, elevated from a baseline of 1.5 mg/dL, along with a urine drug screen positive for cocaine. While initially denying it, he later confirmed he frequently used cocaine. Serum studies five days later indicated elevated levels of anti‐MPO, anti‐PR3, and anti‐P‐ANCA antibodies raising suspicion for levamisole‐induced ANCA vasculitis. A renal biopsy was done, and he was started on plasmapharesis. He developed worsening dyspnea, and a CT scan of the chest revealed bilateral pleural effusions. No pleural fluid could be obtained on ultrasound‐guided thoracentesis; imaging displayed a significant rind to his effusion. His dyspnea eventually improved with plasmapharesis and the initiation of hemodialysis. Renal biopsy ultimately revealed pauci‐immune necrotizing and sclerosing cresenteric glomerulonephritis and tubulointerstitial scarring with superimposed severe acute tubular necrosis. He received cyclophosphamide and daily prednisone. Despite these therapies, his renal function did not recover, and he still required hemodialysis at discharge. He was counseled about his cocaine abuse and resolved to seek outpatient rehabilitation.
This case demonstrates a suspected levamisole‐related vasculitis. Levamisole is a common adulterant found in about 70% of cocaine in the United States. While most cases of levamisole‐related vasculitis are associated with skin lesions and arthralgias, there have been reports of ANCA‐positive levamisole‐related acute kidney injury. Though this patient received immunosuppressive therapy due to his significant renal disease, many levamisole‐related complications can be reversed once exposure stops. Suspicion of cocaine abuse can thus avoid the need for immunosuppressant treatment through education about the risks associated with patients’ drug use.
In cocaine users presenting with possible vasculitis symptoms such as skin lesions, arthralgias or renal failure, physicians should consider levamisole‐associated vasculitis as a potential diagnosis. ANCA testing should be considered in these patients. For some patients, cessation of cocaine use may be sufficient to treat their disease.
To cite this abstract:Craig M, Patel R. An Adulterant and Anca: Levamisole‐Associated Vasculitis. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 395. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/an-adulterant-and-anca-levamisoleassociated-vasculitis/. Accessed March 31, 2020.