54-Year-Old Cocaine User Presented With Enlarging Rash Over Face, Ear, Breasts And Extremities

Painful enlarging rash over face (A) and ears (B)

Cocaine sends high levels of dopamine into parts of your brain and body to control pleasure. The build-up causes a feeling of high and alertness. However, cocaine is a highly addictive psychoactive and stimulant drug with several short-term and serious side effects. In addition, cocaine with adulterants and substitutes can cause severe toxic effects.

The 54-year-old cocaine user was speculated to have Levamisole toxicity resulting from the use of adulterated cocaine. Levamisole is an anthelminthic drug commonly used for the treatment of a parasitic, viral and bacterial infection and presented with a similar toxic effect. Moreover, the female patient presented with a 2 day history of painful enlarging rash over her face, ears, breasts and extremities.

Laboratory examinations revealed neutropenia (neutrophil count, 1070 per cubic millimeter) and lymphopenia (lymphocyte count, 680 per cubic millimeter). In addition, immunofluorescence testing showed the perinuclear pattern (p-ANCA) and the cytoplasmic pattern (c-ANCA). Similarly, proteinase-3 antibody titer of 1:320 was also prevalent in the enzyme linked immunosorbent assay.

A toxicology test was performed to check the patient’s blood, urine and saliva for any drugs or chemicals. The patient’s urine was positive for cocaine and opiates use.

Two days after the patient was admitted, her levamisole level was positive at 920 ng per millilitre. To confirm diagnosis, a biopsy of the skin with the rash was performed, which showed purpura with focal intravascular fibrin formation that was consistent with vasculopathy. For treatment, the patient was given methylprednisolone and predinosone. However, no improvements were seen and the next step involved an extensive debridement of the necrotic tissue.

Clinical findings including, bone marrow suppression and ANCA-positive vasculopathy were consistent with the toxic effects of levamisole. Levamisole is commonly added to cocaine for enhancing the euphoric effect. Similarly, the use of levamisole-adulterated cocaine is an increasing problem. Moreover, should be considered in cocaine users with reticular purpura and neutropenia.

The patient underwent numerous reconstructive surgical procedures and her care was complicated because of recurrent wound infections.


Muirhead, T. T., & Eide, M. J. (2011). Toxic effects of levamisole in a cocaine user. New England Journal of Medicine364(24), e52.

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Dr. Aiman Shahab is a dentist with a bachelor’s degree from Dow University of Health Sciences. She is an experienced freelance writer with a demonstrated history of working in the health industry. Skilled in general dentistry, she is currently working as an associate dentist at a private dental clinic in Karachi, freelance content writer and as a part time science instructor with Little Medical School. She has also been an ambassador for PDC in the past from the year 2016 – 2018, and her responsibilities included acting as a representative and volunteer for PDC with an intention to make the dental community of Pakistan more connected and to work for benefiting the underprivileged. When she’s not working, you’ll either find her reading or aimlessly walking around for the sake of exploring. Her future plans include getting a master’s degree in maxillofacial and oral surgery, settled in a metropolitan city of North America.


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