A 38‐year‐old man presented with complaints of left ear pain and black discoloration for 1 day. He denied any hearing loss, aural fullness, discharge, or fever. His medical history included a history of gout and right fist abscess secondary to MRSA. His family history was unremarkable for autoimmune diseases. He denied any allergies or medication use. By profession he was a nightclub bouncer. He denied any recent travel, sick contacts and any animal or tick exposure. He denied joint pain, oral or nasal ulcers, dry eyes, dry mouth, photosensitivity or Raynaud's phenomenon. On examination his left ear pinna was black, necrotic and tender. There was no aural discharge. Tympanic membrane was normal. The right ear was also normal. Rest of the exam was within normal limits. Laboratory workup revealed a normal CBC and chemistry. Serologies for HIV, hepatitis B and C, and RPR were negative. Further laboratory tests were pursued to rule out autoimmune disorder. His ESR, CRP, C3/C4 and rheumatoid factor were normal. ANA was negative, ANCA proteinase‐3 antibody was negative however, ANCA Myeloperoxidase antibody was positive. Urine toxicology was positive for cocaine and marijuana. On further interrogation the patient confided that these symptoms had occurred once before after coccaine use, and resolved gradually spontaneously. He also confided his last cocaine intake was one day prior to the symptoms at the night club. Biopsy of the left ear showed foci of mild perivascular acute and chronic inflammation with thrombus formation and foci showing extravasated red blood cells consistent with vaso‐occlusive disease or vasculitis. Based on history, examination, laboratory and pathological tests diagnosis of cocaine/ levamisole induced vasculitis was made. The patient was discharged with local Silvadene cream application and the necrosis gradually improved.
Approximately 70% of the cocaine bought illicitly in the United States is cut with product. Levamisole, an antihelminthic and immunomodulatory drug, is hypothesized to increase the release of dopamine, enhancing the effects of the cocaine. Common features of cocaine/levamisole‐induced vasculopathy are cutaneous lesions on nose, cheeks and ear pinna, ANCA MPO antibody positivity (as described in this case) and neutropenia (absent in this case). Although testing for levamisole in serum and urine is commercially available, we did not pursue the test as its short half life (5.6 hours) makes the drug difficult to detect. Beyond the obvious discontinuation of levamisole ‐contaminated cocaine, appropriate management of levamisole induced vasculopathy has yet to be defined.
Cocaine/levamisole‐induced vasculitis should be considered as diagnosis by hospitalists when any patient with a known history of cocaine use presents with lesions of unknown origin.
To cite this abstract:Mansoor M, Siddiqui A, Parikh N. The Mysterious Lesions on My Ear After That Nightclub Experience!. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 427. https://www.shmabstracts.com/abstract/the-mysterious-lesions-on-my-ear-after-that-nightclub-experience/. Accessed February 18, 2019.