Not Your Usual Suspect: Two Cases of Anca Vasculitis

1Harvard Medical School, Boston, MA

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 343

Case Presentation:

Case 1 is a 47‐year‐old man with a 30‐year history of cocaine abuse who was admitted with recurrent cellulitis. Seven months prior he had suffered trauma to his left hand complicated by septic tenosynovitis and abscess requiring surgery and a prolonged course of antibiotics. He subsequently developed polyarthropathy and was treated with indomethacin for presumptive “reactive arthritis.” Over the subsequent 6 months he presented with recurrent bouts of skin swelling and erythema in the left hand along with other areas, each time treated for cellulitis. Two repeat surgical explorations failed to yield any bacteria. On this admission, the patient presented with pain, erythema, and swelling of his right hand and arm without fever or leukocytosis. He received broad antibiotics without improvement. Within 36 hours his right arm symptoms resolved, but his left hand developed focal pain, erythema, and edema. A deep tissue biopsy revealed panniculitis, possibly related to vasculitis. Subsequent evaluation revealed positive c‐ANCA (522 units) and p‐ANCA (12,415 units). His toxicology screen was positive for cocaine. Case 2 is a 41‐year‐old man admitted with 2 days of severe right‐sided pleuritic chest pain, shortness of breath, and hypoxemia. Chest imaging did not reveal pulmonary emboli but was notable for bilateral pleural effusions with atelectasis, septal thickening, and mild ground‐glass opacifications. Three months prior he had noticed “bloody” blisters on his ears, back, biceps and thighs associated with sweats, fatigue, and mild hand swelling. He also reported tender and swollen feet. Additional history of cocaine use was obtained after an otolaryngologist noted near‐total nasal septum perforation without granulomas. Laboratory data revealed an absolute neutrophil count of 895/mm3, a positive ANA (1:160), and a positive p‐ANCA (12,698 units). The lesions were thought to be pur‐puric eruptions secondary to the use of levamisole‐tainted cocaine. He improved on prednisone but was lost to follow‐up until this admission, 3 weeks after his last prednisone dose. Although his urine toxicology screen was negative for cocaine, concern for continued drug use remained, as it was positive for cannabinoids. P‐ANCA titers had increased to 24,303 units. Prednisone was reinstated with mild improvement. Cyclophosphamide was initiated with resolution of symptoms and leukopenia after 2 weeks.


We are presenting 2 cases of ANCA‐positive vasculitis identified in patients actively using intranasal cocaine. This is particularly relevant, as more than 70% of the U.S. cocaine supply is contaminated with levamisole, a veterinary anthelminthic used as a cutting agent. Levamisole‐asso‐ciated vasculitis tends to primarily affect the ears, but recent reports have also described agranulocytosis and ANCA vasculitis.


Hospitalists should be aware that levamisole‐contaminated cocaine has serious health implications and that its systemic manifestations may mimic other conditions.


V. G. Mitchell ‐ none; N. A. Chalfin ‐ none

To cite this abstract:

Mitchell V, Chalfin N. Not Your Usual Suspect: Two Cases of Anca Vasculitis. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 343. Journal of Hospital Medicine. 2011; 6 (suppl 2). Accessed April 5, 2020.

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