Flesh-Eating Vasculitis from Cocaine Adulterant

My father was a small-town preacher. I heard the Bible verse that begins with the phrase “For the wages of sin is death” many, many times. Admittedly, it comes to mind at least once every shift I work in the ED. The cyanotic and apneic heroin overdose patient dropped off by “friends,” the drunk driver who just killed someone, or the pack-a-day cigarette smoker receiving news of lung cancer are all examples of self-destructive scenarios that might stimulate this memory.   I had read about levamisole-adulterated cocaine causing a flesh-destructive vasculitis, but had not seen a patient with this condition until recently. That patient allowed the two videos included with this blog because she wanted others to know about this condition. My father’s words did come to mind again, but I felt nothing but compassion for this weeping middle-aged cocaine addict seeking help for the painful necrotic lesions on her ears, nose, and face.   Levamisole-induced vasculitis has been known since the 1970s. Levamisole was originally an anthelmintic agent that was later found to have significant immunomodulatory properties. It was used in cancer therapy and to treat various skin conditions and immunological renal diseases for a time, but the FDA withdrew it from the human market in 1999. Unfortunately, this veterinary medicine has found a fairly widespread role as an adulterant in illicit cocaine since 2003.   Levamisole not only “cuts” the drug, it potentiates the stimulant effec...
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