MP167LEVAMISOLE-ADULTERATED COCAINE INDUCED SYSTEMIC VASCULITIS WITH PAUCI-IMMUNE CRESCENTIC GLOMERULONEPHRITIS: CASE REPORTS IN SOUTHERN BRAZIL

Abstract

Introduction and Aims: Levamisole has been increasingly used as an adulterant of cocaine during the last decades around the world. Levamisole is an anti-helminthic and immunomodulatory drug known for causing a systemic vasculitis with cutaneous, hematologic and renal involvement. Most of the cases have positive circulating anti-neutrophil cytoplasmatic antibodies (ANCAs) to myeloperoxidase (MPO) and proteinase 3 (PR3). We describe a series of three cases in southern Brazil who were chronic users of cocaine/levamisole, and presented acute kidney injury and/or skin lesions. Methods: In this study we describe a series of three patients who were chronic cocaine users that were followed in our institutions . These patients presented at admission severe acute kidney injury and/or retiform purpura with skin focal necrosis . Posterior investigation rose the suspicion of exposure to cocaine adultared with levamisole with a clinical picture compatible with systemic vasculitis. The medical records of the patients were reviewed, and demographic, clinical, and laboratory data were extracted. Serial urine samples were collected for toxicology analysis for cocaine and levamosile. The presence and percentage of levamisole in the cocaine powder was also determined. The samples were analyzed by immunochromatographic drug screen test (AbonR, Biopharm, Hangzhou, China), and confirmatory testing was performed via gas chromatography-mass spectrometry (GC/MS) in an AgilentR 7890A/5975C system (Wilmington, DE, USA). Results: Two patients exhibited retiform purpura and focal skin necrosis in the ear lobes and legs. All cases had elevated serum creatinine, non-nephrotic proteinuria, anemia, low complement C3, and positive serum ANCA. It was detected antibodies to myeloperoxidase and proteinase 3 in one patient. The three patients were submitted to percutaneous kidney biopsy that showed pauci-immune crescentic glomerulonephritis, with glomerular necrosis and inflammation. The presence of levamisole was confirmed in cocaine samples by gas chromatography-mass spectrometry, with one sample containing 30% of levamisole. Serial measurements of cocaine and levamisole in urine were positive for both drugs at admission and during follow-up. The patients were advised to stop cocaine use, and were treated with immunosuppressive therapy consisting of corticosteroids and monthly intravenous pulses of cyclophosphamide due to the severity of crescentic nephritis. During follow-up the patients resolved the retiform purpura and skin necrosis, and improved renal function, with the best clinical response seen during the time they were abstinent of the drugs. Conclusions: To our knowledge this is the first case series of levamisole-induced skin and renal lesions reported in Brazil. The findings of retiform purpura, crescentic glomerulonephritis, and positive anti-MPO and anti-PR3 antibodies were compatible with exposure to levamisole. Levamisole-adulterated cocaine has been increasingly used around the world, which should heighten the suspicion for the potentially serious toxic effects of this harmful combination. In addition to abstinence from drugs, early institution of immunosuppressive therapy may lead to better clinical outcomes.