002. BREAKING BAD IN SUBURBIA: A CASE OF DRUG-INDUCED VASCULITIS

Abstract

Background: Levamisole is a synthetic compound used as an anthelmintic. It has been found in adulterated cocaine linked with ANCA associated vasculitis. Methods: This is the case of a 58-year-old male presented to accident and emergency with dysphasia. A stroke was suspected and an urgent CT head scan, demonstrated a lacunar infarct. He was commenced on aspirin 300mg, clopidogrel 75mg, lansoprazole 30mg, and Atorvastatin 40mg. His secondary risk factors included hypertension, obesity and a smoking history. Blood tests at the time of admission demonstrated stage three chronic kidney disease and protein and blood on urine dip. A full nephritic screen was performed. ANCA was positive in a cytoplasmic pattern, with a positive PR3 of 72U/ml. Urine demonstrated 122 red blood cells but no casts. There was an unfortunate delay of six weeks before renal review. A kidney biopsy was conducted which demonstrated advanced scarring of his kidneys with obsolete glomeruli, however there was still activity in one crescent. A diagnosis of C-ANCA positive renal vasculitis was given and he was commenced on Prednisolone 60mg and Adcal D3. An urgent referral to rheumatology was made for consideration for IV cyclophosphamide. The rheumatology consultation elicited a history of long-standing poor memory, which appears to have predated his stroke. His MRI subsequent to his stroke showed involvement of the left corona radiate, discrete focus on the right, with additional hyper-intense foci scattered within the white matter of both cerebral hemispheres. Review of CT and MRI scans demonstrated evidence of very significant paranasal sinus disease. There was some evidence of bony destruction including the medial orbital wall on the right and some thickening of the medial extra-ocular muscle. There was increased signal at the same site on the MRI. Surprisingly he denied any nasal symptoms. He admitted otherwise of some wheeze in the chest since the stroke but there were no other neurological symptoms, no hearing symptoms and he denied any constitutional symptoms. There was a history of DVT 4 years previously and a 10yr history of cocaine abuse up until the time of his stroke. He was diagnosed granulomatosis with polyangitis. The cocaine abuse we believe may have played a role in induction of his disease. Treatment plan currently is for 6 cycles of cyclophosphamide, reducing dose prednisolone with plans for Azathioprine as a DMARD in the future. Results: Differentiating between idiopathic vasculitis from drug and induced vasculitis can be challenging especially when serology is positive. ANCA positivity can be associated with both idiopathic and drug-induced vasculitis. Conclusion: This case highlights the need to take a thorough drug and social history. Despite review by several physicians the 10-year history of cocaine abuse was not elicited until 5 months after first contact.