Accepted Manuscript

Levamisole-induced vasculopathy: a systematic review

Anaı̈s Dartevel , Benjamin Chaigne , Laurence Moachon ,

Florian Grenier , Nicolas Dupin , Loı̈c Guillevin ,
Laurence Bouillet , Luc Mouthon

PII: S0049-0172(18)30254-3
DOI: https://doi.org/10.1016/j.semarthrit.2018.07.010
Reference: YSARH 51378

To appear in: Seminars in Arthritis & Rheumatism

Received date: 28 April 2018

Revised date: 27 June 2018
Accepted date: 23 July 2018

Please cite this article as: Anaı̈s Dartevel , Benjamin Chaigne , Laurence Moachon ,
Florian Grenier , Nicolas Dupin , Loı̈c Guillevin , Laurence Bouillet , Luc Mouthon , Levamisole-
induced vasculopathy: a systematic review, Seminars in Arthritis & Rheumatism (2018), doi:
https://doi.org/10.1016/j.semarthrit.2018.07.010

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 ACCEPTED MANUSCRIPT

Levamisole-induced vasculopathy: a systematic review

Anaïs Dartevel1,2, Benjamin Chaigne1, Laurence Moachon3, Florian Grenier4, Nicolas Dupin5,

Loïc Guillevin1, Laurence Bouillet2, Luc Mouthon1

1
Service de Médecine Interne, hôpital Cochin, Centre de Référence pour les maladies

systémiques autoimmunes rares d’Ile de France, DHU Authors (Autoimmune and Hormonal

Diseases), Université Paris Descartes, Sorbonne Paris Cité, Assistance Publique-Hôpitaux de

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Paris (AP-HP), Paris, France;

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2
Service de Médecine Interne, Centre national de référence des angiœdème (CREAK),

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Universités des Alpes-Grenoble 1, 38041 Grenoble, France;
3

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Service de Pharmacologie, Hôpital Cochin, AP-HP, and Université Paris Descartes,

Sorbonne Paris Cité, Paris.

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4
Service de médecine légale, Universités des Alpes-Grenoble 1, 38041 Grenoble;
5
Service de Dermatologie, Hôpital Cochin, AP-HP, and Université Paris Descartes, Sorbonne
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Paris Cité, Paris.

Address correspondence to:

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Dr. Luc Mouthon,

Department of Internal Medicine,
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Hôpital Cochin,
27, rue du Faubourg Saint-Jacques,
75679 Paris Cedex 14, France.
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Phone: +33 (0)1 58 41 20 31;

Fax: +33 (0)1 58 41 14 50;
E-mail: luc.mouthon@aphp.fr
Running title: levamisole induced vasculopathy
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Key words: levamisole; ANCA; vasculitis; thrombotic vasculopathy

No authors declare conflict of interest or financial support

Abstract

Objective. To characterize levamisole-induced vasculopathy.

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Methods. We performed a systematic review searching MEDLINE for articles published from

1972 to 2016.

Results. We retrieved 357 references and abstracts and selected 111 articles. Levamisole-

induced vasculopathy was reported in 192 patients, with a female predominance (n=122,

63.5%). Median [interquartile range] age was 44 [38-50]. Skin was the most frequently

involved organ (n=182, 94.8%). Cutaneous lesions were mostly on the face (n=136, 70.8%),

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especially the ears. Purpura (n=131, 68.2%) was the most reported cutaneous lesion. Organ

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involvement included acute renal failure (n=24, 12.5%), and pulmonary involvement (n=20,

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10.4%). Anti-neutrophil cytoplasmic antibodies (ANCAs) were found in 167/178 patients

(93.8%), with both anti-myeloperoxydase and anti-proteinase 3 specificity reported in 51/118

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patients (43.2%). Anti-phospholipid (APL) antibodies were found in 93/137 patients (67.9%).
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Leukopenia was detected in 69/138 patients (50%). Skin biopsies identified vasculitis and

thrombotic vasculopathy in 73/148 (49.3%) and 62/148 (41.9%) patients, respectively. The
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outcome was favourable in 116/134 patients (86.6%), but relapses were reported in 33

(28.4%), mainly on levamisole re-exposure.

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Conclusion. Levamisole-induced vasculopathy is characterized by a female predominance,

skin involvement, ANCA and/or APL antibody positivity, leukopenia, vasculitis or vascular
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thrombotic histological lesions, and despite possible systemic involvement, a favourable

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outcome with levamisole interruption.

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Introduction

Levamisole is an imidazothiazole derivative that was commercialized in 1971 in the United

States as an anthelmintic agent. Because of its immunomodulatory properties, it was also used

to treat autoimmune and/or systemic conditions including nephrotic syndrome, rheumatoid

arthritis, and solid tumors. Levamisole was withdrawn from the market in the United States in

2000 and in Canada in 2003 because of side effects including agranulocytosis, vasculitis and

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leukoencephalopathy [1-3]. It is still used in veterinary clinics in the United States and South

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America.

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Since 2003, levamisole has also been used to adulterate cocaine. Levamisole reduces the cost

of cocaine preparation [4] and increases the release of norepinephrine in peripheral tissues

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and dopamine in the brain thereby improving neurotransmission in the central nervous system
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[5, 6] and increasing the effects and duration of cocaine [5,7]. Furthermore, aminorex, an

amphetamine derivative, is a metabolite of levamisole [5,8,9], so its recreational use is

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increasing. In the United States, levamisole has been detected in 70% of cocaine seized by

customs in 2009 [10] and up to 88% of urine samples of cocaine users [11,12]. In Europe
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also, levamisole has been increasingly found in 85.3% of cocaine lots [13]. More recently, in

Germany, levamisole was detected in 83% of cocaine-positive serum samples [14].

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In parallel, cases of agranulocytosis or vasculitis and/or thrombotic vasculopathies associated

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with cocaine intake have been reported since 2003, thereby implicating levamisole in the

occurrence of these symptoms [15-18]. Indeed, when levamisole was used as a medical
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treatment, side effects such as vasculopathy and/or autoimmune manifestations were reported

in 0.5% to 3% of patients [19,20,21]. These side effects were mainly purpura and/or

necrotizing lesions associated with the detection of autoantibodies (anti-neutrophil

cytoplasmic antibodies [ANCAs] and anti-phospholipid [APL] antibodies [Abs]), which

resolved after levamisole weaning/interruption [19-21].

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We performed a systematic literature review of vasculitis or other vasculopathies associated

with levamisole intake, both as adverse events following its use as a drug or as a result of its

consumption in adulterated cocaine, for better analysis of the clinical presentation,

immunological and histological aspects as well as prognosis and treatment of this condition.

Materials and Methods

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Selection of articles

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We searched MEDLINE via PubMed for articles of research, with no restriction on language

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or publication type, that were published from January 1977 to July 2016 and investigated the

association between levamisole and vasculitis, necrosis, purpura, vasculopathy, or ANCAs

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and between cocaine and purpura, vasculitis, or ANCAs. For articles reporting levamisole
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consumption as a cocaine adulterant, only those published after December 2002 were selected

because cocaine was adulterated with levamisole only after 2003. Articles reporting vascular
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complications of levamisole were selected. We excluded articles reporting only midline

destruction and gangrene/ischemia occurring as a result of vasospasm, stroke and/or

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myocardial infarction because cocaine is directly responsible for these complications, which

were reported long before 2003. Other exclusion criteria were lack of clinical information,
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unclear vasculitis/vasculopathy etiology, and absence of vascular involvement.

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Data collection

For all articles included, we collected data with a standardized form, including age, sex, past
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history, clinical manifestations, biological and immunological characteristics, pathological

data as well as treatment and outcome.

Patients were divided into 2 groups by levamisole consumption: medical consumers of

levamisole (group 1) and recreational consumers of levamisole due to cocaine addiction

(group 2).

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Statistical analyses

Data are reported as number (%) or median (interquartile range [IQR]). Statistical analysis

involved using GraphPad Prism 6 (GraphPad, La Jolla, CA, USA). Differences between

patient groups were compared by Student t test for continuous data and Fischer exact test for

categorical data. All tests were two-sided, with p <0.05 considered statistically significant.

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Results

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Selection of articles

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Among the 357 articles retrieved, 126 were selected on the basis of the abstract (118 in

English, 7 in Spanish and 1 in Italian) (Figure 1). We excluded 22 articles associated with

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cocaine consumption and 5 to hematological complications. A further 15 were excluded
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for insufficient clinical data or already reported (n=9) or unclear cause of vasculitis or

vasculopathy etiology (n=6). Overall, 111 articles were selected for the analysis, reporting
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193 patients including one reported in 2 separate manuscripts. One of the cases reported in a

series was excluded because of the absence of vasculitis or vasculopathy. Finally, we

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identified 192 patients. (Table of patients and references in supplemental data)

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Characteristics of patients

Group 1 (medical consumption) consisted of 13 patients (6 females, 6 males and one

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individual of unreported sex), mostly children with nephrotic syndrome. Median [IQR] age

was 11 [10-31]. Symptoms appeared between 1 and 44 months after the initiation of
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levamisole. All patients were on levamisole at the time of symptom onset, except one who

discontinued the treatment 3 months before the clinical manifestations.

Group 2 (recreational consumption) consisted of 179 patients (116 females, 54 males and 9

individuals of unreported sex). Median [IQR] age was 45 [40-50]. Data on cocaine

consumption modality were not available for 96 patients. Various cocaine consumption

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modalities identified included crack (n=54/83, 65.1%), intranasal administration (n=27/83,

32.6%), crack and intranasal administration (n=1/83, 1.2%) and intravenous administration

(n=1/83, 1.2%).

Research on levamisole and cocaine

Among patients in group 2, cocaine was detected in 95/105 (90.5%); in urine for 85 (89.5%)

and in hair for 2 (2.1%), with no mention of the type of sample tested for 8 (8.4%). In group

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2, 45/54 patients (83.3%) were positive for levamisole, detected in urine or serum for 37

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(82.2%), in the cocaine lot for 5 (1.1%) and in hair for 2 (4.4%). One patient who was initially

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negative for levamisole was positive during follow-up.

Clinical presentation of levamisole-associated vasculopathy (Tables 1 and 2)

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The most frequent clinical symptoms, related to skin involvement, were observed in 182
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patients (94.8%). Skin lesions were mainly purpura (n= 131, 68.2%), which were necrotic or

retiform. Other skin lesions were necrosis without evidence of purpura (n=29, 15.1%), blisters
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(n=42, 21.9%), ulcerations (n=34, 17.7%), livedo (n=7, 3.6%) or papules or erythematous

plaques (n=22, 11.5%). Different types of lesions could coexist. Skin lesions most frequently
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involved the face (n=136, 70.8%), prominently the ears (n=119, 62%), although cheeks

(n=35, 18.2%) and the nose (n=23, 12%) could also be involved. The lower limbs (n=135,
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70.3%), upper limbs (n=99, 51.6%) and trunk (n=51, 26.6%) were also frequently involved.
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Arthralgias were reported in 55 patients (28.6%), arthritis in 8 (4.2%) and ear, nose and throat

(ENT) involvement in 29 (15.1%) with midline destruction, rhinitis and/or oral or tracheal
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ulcers.

Organ damage was less frequent, with renal insufficiency in 24 patients (12.5%) and

pulmonary involvement in 20 (10.4%), including 6 (3.1%) with alveolar haemorrhage.

Neurological involvement was rare (n=2, 1%), consisting in confusion.

Biological and immunological data

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An inflammatory syndrome, with increased C-reactive protein (CRP) level, was detected in

48/57 patients tested (84.2%), with median [IQR] CRP level 21.5 mg/l [9.8-74.3].

Leukopenia was the most frequent haematological abnormality, found in 69/138 patients

(50%), with median [IQR] leukocyte and neutrophil counts of 3.3 g/l [2.4-4.8] and 1 g/l [0.5-

2.4], respectively. Neutropenia was reported in 57/132 patients tested (43.2%), including 13

(9.8%) with agranulocytosis. These abnormalities were associated with anemia in 17 patients,

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with median [IQR] haemoglobin count 8.9 g/l [6.7-9.9], and associated with

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thrombocytopenia in 2 cases, with median [IQR] platelet count 103 g/l [100.5-105.5].

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Autoantibodies were identified in most patients (Table 3). ANCAs were detected in 167/178

patients tested (93.8%), mainly perinuclear ANCAs (n=99/167, 59.3%) as assessed by

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indirect immunofluorescence (IF) assay. ANCA specificity was studied by enzyme linked
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immunosorbent assay in 118 patients. Anti-myeloperoxydase (MPO) and anti-proteinase 3

(PR3) Abs were frequently associated (n=51/118, 43.2%); anti-MPO Abs alone were
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identified in 38/118 patients (32.2%) and anti-PR3 Abs alone in n=18/118 (15.3%).

Among the 137 patients tested for APL Abs, 93 (67.9%) had at least one of these
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autoantibodies, with detection of anti-cardiolipin Abs in 64 (46.7%), lupus anticoagulant in 58

(42.3%) and anti-ß2-glycoprotein1 (anti-ß2GP1) Abs in 11 (8%). Seven patients (5.1%) were
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triple positive, 24 (17.6%) had both anti-cardiolipin Abs and lupus anticoagulant, and 4 (3%)
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had both anti-cardiolipin and anti-ß2GP1 Abs.

In all, 75/144 patients (52.1%) were positive for anti-nuclear Abs (ANA). Reported
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specificities were anti-deoxyribonucleic acid (anti-DNA) Abs (n=15), anti-nucleo-protein Abs

(n=1), anti-Sjögren’s syndrome-related antigen Abs (n=2), anti-Sjögren’s syndrome-related

antigen and anti-DNA Abs (n=1), anti-histone Abs (n=2), anti-Smith Abs (n=1) and no

identified specificity (n=4). No information on specificity was available for 40 patients.

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Complement C3 and C4 protein levels were quantified in 87 patients; concentrations were

within the normal range for 58 (66.7%); C3 and C4 levels were decreased for 14 (16.1%); C3

level was decreased and C4 level normal for 4 (4.6%); and C4 level was decreased with

normal C3 level for 11 (12.6%).

Cryoglobulin was detected in 12/63 patients (19%) and found weak (n= 1), detectable (n=2),

trace (n=1), and positive (n=8). In all, 10/12 patients with cryglobulin underwent hepatitis C

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virus (HCV) serology and 2 were positive, including 1 with negative HCV PCR findings and

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1 in whom PCR was not performed. Among patients with cryoglobulinemia, 4 had cutaneous

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vasculitis, 6 thrombotic vasculopathy without vasculitis and 1 unspecific cutaneous histology

and 1 skin biopsy findings (no indirect IF data available).

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Among 60 patients tested, none had evidence of HIV infection. Two of 64 patients (3.1%) had
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unspecified “positive” hepatitis B virus serology and 8/70 (11.4%) positive HCV serology.

Except for the 2 patients positive for cryoglobulin, HCV PCR results were not reported.
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Pathology study

In all, 148/192 patients (77.1%) had skin biopsies. Two dominant patterns were identified:
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vasculitis, and thrombotic vasculopathy without vasculitis. Vasculitis was detected in 73

biopsies (49.3%) and described as leukocytoclastic in 47 (64.4%) and necrotizing in 5 (6.8%).

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Thrombotic vasculopathy without vasculitis was identified in 62 biopsies (41.9%); for 42

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patients, APL Ab status was available. Strikingly, 35 patients (56.5%) were positive for APL

Abs. For eight patients; results were interpreted as compatible with pyoderma gangrenosum,
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with dermal neutrophil infiltrates; for 5 of these patients, vasculitis lesions were also

identified, together with thrombosis in 3. In 10 biopsies, non-specific inflammatory lesions

were identified, without evidence of vasculitis. Indirect IF assay was performed for 21

biopsies and was positive for immunoglobulins (Igs) and/or C3 deposits in 16 (76.2%)

(IgM=12, IgG=8, IgA=8, C3=15).

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Among 24 patients with acute renal failure, 13 underwent renal biopsy. Crescentic

glomerulonephritis was identified in 10/13 biopsies (77%); 2 were pauci-immune because of

no deposits seen on IF assay, and 1 showed IgG, IgM and C3 deposits on IF assay (IF data not

specified for others). One biopsy identified immune-mediated glomerulonephritis with IgG

and C3 deposits, and another showed an association of crescentic glomerulonephritis and

membranous nephropathy with IgG, IgM, C3 and C1q deposits. The last one showed

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glomerulonephritis with thrombotic microangiopathy.

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Treatment and outcome

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Information on treatment and/or outcome was available for 151 (78.6%) and 134 (69.8%)

patients, respectively. Overall, 28 did not receive any treatment or received only symptomatic

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treatment (the treatment did not include surgery), and 85 received corticosteroids; 15 received
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only corticosteroids. Prednisone was the most frequent corticosteroid prescribed. The median

[IQR] starting dose was 60 mg/d [40-81.3]. Treatment was in general brief.
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In total, 20/151 patients received immunosuppressants, associated with corticosteroids for 15

and with corticosteroids and plasmapheresis for 3. Immunosuppressants included

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cyclophosphamide (n=13, 8.6%), rituximab (n=2, 1.3%), methotrexate (n=2, 1.3%) and

thalidomide (n=1, 0.7%). For 2 patients, the type of immunosuppressant prescribed was not
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specified. Nine patients underwent plasmapheresis with a combination of corticosteroids,

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including 3 with immunosuppressants.

Skin surgery was performed in 21/151 patients (14%) because of severe decaying lesions.
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Surgery consisted of skin graft in 15 patients (10%), debridement in 14 patients (9.3%), and

amputation of the nose and leg in 1 patient (0.7%) Debridement was associated with skin graft

in 9 patients; 4 of these also received corticosteroids, including one a combination of

corticosteroids and plasmapheresis.

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Antibiotics were prescribed for 23/151 patients, combined with corticosteroids in 8 and with

growth factors in 2. Three patients received unspecified anticoagulants, and 4 received

another treatment (colchicine, non-steroidal anti-inflammatory drugs, phentolamine and

pentoxifylline).

Information on discontinuation of levamisole was available for 65/151 patients. It was

discontinued in 54/65 (83.1%); 18 of these did not receive any additional medication and had

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a favourable outcome.

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The evolution was favourable for 116/134 patients (86.6%), with regression of clinical

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symptoms. Three patients (2.2%) died, including one with early necrotizing pneumonia. Two

patients died during follow-up: 1 of overdose (2 years later) and another who underwent

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dialysis who died of cerebral haemorrhage (several months later). Among the 24 patients who
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presented acute renal insufficiency, 10 (41.7%) recovered; in 7 (29.2%), chronic renal

insufficiency developed; and 3 showed relapse after reexposure to levamisole (no data
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available for the 4 remaining patients).

Other complications included persistent skin lesions in 5/134 patients (3.7%) without
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levamisole exposure disruption, infection of skin lesions in 2 patients (1.5%), cortico-

dependence in 1 patient (0.7%), and amputation due to worsening of the skin lesions in 1
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patient (0.7%).
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Overall, 33/134 (28.4%) patients showed vasculopathy relapse. When levamisole had been

stopped, its reintroduction was systematically followed by vasculopathy relapse.

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Discussion

Levamisole is the most frequent cocaine adulterant, and its use is increasing [22]. Indeed, the

proportion of cocaine lots containing levamisole has increased during the last few years, along

with an increase in levamisole concentration in cocaine lots [4,22]. Therefore, specificities of

levamisole-induced vasculopathy need to be identified. This systematic review revealed

levamisole-induced vasculopathy occurring frequently in middle-aged women and

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characterized by skin involvement, especially necrotic purpura located in the ears, leuko-

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neutropenia, ANCAs and/or APL Abs and good prognosis on levamisole disruption.

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Cocaine consumers are more often men between 18 and 25 years old [23]. Middle-aged

women are not the most frequent cocaine consumers, so we show a sex and age susceptibility

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for the development of levamisole-induced vasculopathy. This susceptibility was not found in
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medical consumers of levamisole but could be explained by the main indication for

levamisole, nephrotic syndrome, which mainly concerns young boys. In our series, ENT and
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pulmonary involvement were found only in recreational consumers of levamisole. Indeed,

cocaine is known to induce midline destructive lesions characterized by nasal obstruction,

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epistaxis, necrotizing ulcerative lesions, extensive crusting, and septal perforation [24, 25] as

well as alveolar haemorrhage, pneumonia, interstitial pneumonia, and pulmonary edema due
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to alveolar damages [26,27]. Therefore, levamisole-induced vasculopathy shares symptoms

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with cocaine intoxication spectrum but appears to be more prevalent in middle-aged women.

In this study, patients with levamisole-induced vasculopathy had striking antibody status.
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Indeed, ANCA specificity was frequently positive for both anti-MPO and anti-PR3 Abs,

which is unusual [28,29]. As well, in patients with ANCA-associated vasculitis (AAV), the

detection of APL Abs is also very rare. To the best of our knowledge, this association was

reported once [30]. In our review, 67.9% patients were positive for APL Abs. Therefore,

double ANCA specificity and/or positivity for APL Abs in patients with AAV could be

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considered a “red flag” for cocaine intake and should lead practitioners to confirm it.

Moreover, this excess immune response is corroborated by histological findings. Indeed, we

highlight two main patterns from biopsies of patients with levamisole-induced vasculopathy:

vasculitis and/or thrombotic vasculopathy. Of note, many patients with thrombotic

vasculopathy were positive for APL Abs.

The differential diagnoses of levamisole-induced vasculopathy mainly include AAV,

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especially granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA).

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Diagnosis of levamisole-induced vasculopathy can be difficult because of a half-life of

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levamisole of about 6 hr [31]. Our series highlights differences between levamisole-induced

vasculopathy and AAV, which can be used as red flags to differentiate these conditions. For

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example, skin involvement is less common in GPA and MPA than in levamisole-induced
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vasculopathy, whereas renal, pulmonary and peripheral nerve involvement are more frequent

in GPA and MPA, and ear involvement has not been described in MPA [28,29]. Among
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possible specificities, face involvement seems to be frequent in levamisole-induced

vasculopathy and rare in AAV. Moreover, skin lesions are often severe in levamisole-induced
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vasculopathy (requiring skin surgery in 14% of cases), whereas in GPA, no cases of

amputation associated with skin wound and only one case of skin graft for leg ulcers were
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reported [32]. Biologically, levamisole-induced vasculopathy causes leukopenia or

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neutropenia, which is not common in GPA and MPA [28,29]. Finally, levamisole-induced

vasculopathy relapse is clearly associated with levamisole reexposure, which is a major

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difference from AAV, for which relapse is unpredictable.

Our work has some limitations, related to its retrospective nature and common to every

literature review. Some data were missing in publications. We cannot exclude the possibility

of misdiagnosis between AAV and levamisole-induced vasculopathy because the presence of

levamisole was not sought and/or not reported for most of the cases. Moreover, when

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investigated, because of its half-life, some tests could have been falsely negative, which

implies an underestimation of the number of levamisole-induced vasculopathy cases. Still, to

the best of our knowledge, our series is the largest of levamisole-induced vasculopathy cases.

We cannot exclude that APL Abs were only transient because their status was not checked 12

weeks later in most cases, as recommended for APL syndrome [33]. For the rare cases in

which ALP Abs were later checked, these were often negative (n=8/10, 80%).

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In conclusion, levamisole-induced vasculopathy is predominantly seen in middle-aged women

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and shows skin involvement, especially ear purpura and necrotic lesions; leuko-neutropenia;

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and ANCAs with double specificity and/or APL Abs. Levamisole must be considered in this

presentation because stopping levamisole exposure is essential for remission. When ANCA

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vasculitis is suspected, we must ask patients about cocaine consumption and if necessary, test
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them for cocaine and levamisole presence in hair.
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Acknowledgements

The autthors want to thank the patient association “France Vascularites” for its support.
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References

1. Larocque A, Hoffman RS. Levamisole in cocaine: unexpected news from an old

acquaintance. Clin Toxicol (Phila). 2012 Apr;50(4):231–41.

2. Williams GT, Johnson SA, Dieppe PA, Huskisson EC. Neutropenia during treatment of

rheumatoid arthritis with levamisole. Ann Rheum Dis. 1978 Aug;37(4):366–9.

3. Thompson JS, Herbick JM, Klassen LW, Severson CD, Overlin VL, Blaschke JW, et al.

T
Studies on levamisole--induced agranulocytosis. Blood. 1980 Sep;56(3):388–96.

IP
4. Auffenberg C, Rosenthal LJ, Dresner N. Levamisole: a common cocaine adulterant with

CR
life-threatening side effects. Psychosomatics. 2013 Dec;54(6):590–3.

5. Raymon LP, Isenschmid DS. Letter to the editor: The possible role of levamisole in

US
illicit cocaine preparations. J Anal Toxicol. 2009 Dec;33(9):620–2.
AN
6. Chang A, Osterloh J, Thomas J. Levamisole: a dangerous new cocaine adulterant. Clin

Pharmacol Ther. 2010 Sep;88(3):408–11.

M

7. Tallarida CS, Egan E, Alejo GD, Raffa R, Tallarida RJ, Rawls SM. Levamisole and

cocaine synergism: a prevalent adulterant enhances cocaine’s action in vivo.

ED

Neuropharmacology. 2014 Apr;79:590–5.

8. Bertol E, Mari F, Milia MGD, Politi L, Furlanetto S, Karch SB. Determination of

PT

aminorex in human urine samples by GC-MS after use of levamisole. J Pharm Biomed
CE

Anal. 2011 Jul 15;55(5):1186–9.

9. Hofmaier T, Luf A, Seddik A, Stockner T, Holy M, Freissmuth M, et al. Aminorex, a

AC

metabolite of the cocaine adulterant levamisole, exerts amphetamine like actions at

monoamine transporters. Neurochem Int. 2014 Jul;73:32–41.

10. Nationwide Public Health Alert Issued Concerning Life-Threatening Risk Posed by

Cocaine Laced with Veterinary Anti-Parasite Drug

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 ACCEPTED MANUSCRIPT

11. Lynch KL, Dominy SS, Graf J, Kral AH. Detection of levamisole exposure in cocaine

users by liquid chromatography-tandem mass spectrometry. J Anal Toxicol. 2011

Apr;35(3):176–8.

12. Buchanan JA, Heard K, Burbach C, Wilson ML, Dart R. Prevalence of levamisole in

urine toxicology screens positive for cocaine in an inner-city hospital. JAMA. 2011 Apr

27;305(16):1657–8.

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13. Eiden C, Diot C, Mathieu O, Mallaret M, Peyrière H. Levamisole-adulterated cocaine:

IP
what about in European countries? J Psychoactive Drugs. 2014 Dec;46(5):389–92.

CR
14. Dziadosz M, Klintschar M, Teske J. Letter to the editor--Consumption of levamisole in

15.
US
cocaine preparations. J Forensic Sci. 2015 Mar;60(2):538.

Knowles L, Buxton JA, Skuridina N, Achebe I, Legatt D, Fan S, et al. Levamisole

AN
tainted cocaine causing severe neutropenia in Alberta and British Columbia. Harm

Reduct J. 2009;6:30.
M

16. Centers for Disease Control and Prevention (CDC). Agranulocytosis associated with
ED

cocaine use - four States, March 2008-November 2009. MMWR Morb Mortal Wkly

Rep. 2009 Dec 18;58(49):1381–5.

PT

17. Lee KC, Ladizinski B, Federman DG. Complications associated with use of levamisole-

contaminated cocaine: an emerging public health challenge. Mayo Clin Proc. 2012
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Jun;87(6):581–6.
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18. Espinoza LR, Perez Alamino R. Cocaine-induced vasculitis: clinical and immunological

spectrum. Curr Rheumatol Rep. 2012 Dec;14(6):532–8.

19. Barbano G, Ginevri F, Ghiggeri GM, Gusmano R. Disseminated autoimmune disease

during levamisole treatment of nephrotic syndrome. Pediatr Nephrol. 1999

Sep;13(7):602–3.

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20. Bagga A, Hari P. Levamisole-induced vasculitis. Pediatr Nephrol. 2000 Sep;14(10-

11):1057–8.

21. Rongioletti F, Ghio L, Ginevri F, Bleidl D, Rinaldi S, Edefonti A, et al. Purpura of the

ears: a distinctive vasculopathy with circulating autoantibodies complicating long-term

treatment with levamisole in children. Br J Dermatol. 1999 May;140(5):948–51.

22. Caudevilla F, Ventura M, Fornís I, Barratt MJ, Vidal C, Lladanosa CG, et al. Results of

T
an international drug testing service for cryptomarket users. Int J Drug Policy. 2016

IP
Sep;35:38–41

CR
23. Substance Abuse and Mental Health Services Administration: Results from the 2013

National Survey on Drug Use and Health: Summary of National Findings.

US
24. Trimarchi M, Bertazzoni G, Bussi M. Cocaine induced midline destructive lesions.
AN
Rhinology. 2014 Jun;52(2):104–11.

25. Trimarchi M, Bussi M, Sinico RA, Meroni P, Specks U. Cocaine-induced midline

M

destructive lesions - an autoimmune disease? Autoimmun Rev. 2013 Feb;12(4):496–

500.
ED

26. Tseng W, Sutter ME, Albertson TE. Stimulants and the lung: review of literature. Clin

Rev Allergy Immunol. 2014 Feb;46(1):82–100.

PT

27. Mégarbane B, Chevillard L. The large spectrum of pulmonary complications following

CE

illicit drug use: features and mechanisms. Chem Biol Interact. 2013 Dec 5;206(3):444–

51.
AC

28. Almouhawis HA, Leao JC, Fedele S, Porter SR. Wegener’s granulomatosis: a review of

clinical features and an update in diagnosis and treatment. J Oral Pathol Med. 2013

Aug;42(7):507–16.

29. Villiger PM, Guillevin L. Microscopic polyangiitis: Clinical presentation. Autoimmun

Rev. 2010 Oct;9(12):812–9.

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30. Castellino G, La Corte R, Santilli D, Trotta F. Wegener’s granulomatosis associated

with antiphospholipid syndrome. Lupus. 2000;9(9):717–20.

31. Trehy ML, Brown DJ, Woodruff JT, Westenberger BJ, Nychis WG, Reuter N, et al.

Determination of levamisole in urine by gas chromatography-mass spectrometry. J Anal

Toxicol. 2011 Oct;35(8):545–50

T
32. Santana ANC, Takagaki TY, Barros JM, Antunes T, Parra ER, Capelozzi VL, et al. Re:

IP
giant leg ulcer in Wegener’s granulomatosis treated with plasmapheresis and skin graft.

CR
Dermatol Surg. 30(8):1182–3.

33. Miyakis S, Lockshin MD, Atsumi T, Branch DW, Brey RL, Cervera R, et al.

US
International consensus statement on an update of the classification criteria for definite

antiphospholipid syndrome (APS). J Thromb Haemost. 2006 Feb;4(2):295–306

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Abbreviations:

Antibodies: Abs

Anti-ß2-glycoprotein1: anti-ß2GP1

Anti-deoxyribonucleic acid: anti-DNA

Anti-neutrophils cytoplasmic antibodies: ANCA

ANCA-associated vasculitis: AAV

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Anti-nuclear : ANA

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Anti-phospholipid: APL

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C-reactive protein: CRP

Granulomatosis with polyangiitis: GPA

Hepatitis C: HCV US
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Human immunodeficiency virus: HIV

Interquartile range: IQR

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Immunofluorescence: IF

Immunoglobulin: Ig
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Microscopic polyangiitis: MPA

Myeloperoxidase: MPO
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Proteinase 3: PR3
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Legend to figures

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Figure 1. Flow chart of the search for articles reporting levamisole-induced vasculopathy.
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Table 1. Systemic manifestations of 192 patients with levamisole-induced vasculopathy:

medical consumers of levamisole (group 1) and recreational consumers of levamisole due to

cocaine addiction (group 2).

All patients Group 2

Systemic manifestations Group 1 n=13
n=192 n=179
Skin involvement 182 (94.8) 13 (100) 169 (94.4)

Fever 36 (18.8) 5 (38.5) 31 (17.3)

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Arthralgia 55 (28.6) 3 (23.0) 52 (29.1)

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Arthritis 8 (4.2) 0 (0) 8 (4.4)

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Myalgia 14 (7.3) 0 (0) 14 (7.8)

ENT involvement 29 (15.1) 0 (0) 29 (16.2)

Midline destruction US
10 (5.2) 0 (0) 10 (5.6)
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Oral or tracheal ulcers 15 (7.8) 0 (0) 15 (8.3)

Rhinitis 1 (0.5) 0 (0) 1 (0.6)

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Acute renal failure 24 (12.5) 0 (0) 24 (12.5)

Pulmonary involvement 20 (10.4) 0 (0) 20 (11.1)

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Alveolar hemorrhage 6 (3.1) 0 (0) 5 (2.8)

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Pneumonia 6 (3.1) 0 (0) 6 (3.1)

Interstitial pneumonia 1 (0.5) 0 (0) 1 (0.6)

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Bilateral patchy infiltration 1 (0.5) 0 (0) 1 (0.6)

Pulmonary nodules 2 (1) 0 (0) 2 (1.1)

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Pleurisy 1 (0.5) 0 (0) 1 (0.6)

Pneumonia and pleuropericarditis 1 (0.5) 0 (0) 1 (0.6)

Neurological involvement 2 (1) 0 (0) 2 (1.1)

Confusion 2 (1) 0 (0) 2 (1.1)

Abbreviations: ENT: ear, nose, and throat

Data are number of patients (%).

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Table 2. Cutaneous lesions of 192 patients with levamisole-induced vasculopathy.

All patients Group 1 Group 2

Cutaneous lesions
n=192 n=13 n=179
Type of lesion

Purpura 131 (68.2) 8 (61.5) 123 (68.7)

Retiform purpura 53 (27.6) 1 (7.7) 52 (29.1)

Necrotic purpura 60 (31.3) 5 (38.5) 55 (30.7)

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Necrosis without purpura 29 (1.1) 1 (7.7) 28 (15.6)

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Blister 42 (21.9) 4 (30.8) 38 (21.2)

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Ulceration 34 (17.7) 1 (7.7) 33 (18.4)

Erythematous plaque or papule 22 (11.5) 1 (7.7) 21 (11.7)

Livedo US
7 (3.6) 1 (7.7) 6 (3.4)
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Location

Face 136 (70.8) 9 (69.2) 127 (71)

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Ears 119 (62.0) 8 (61.5) 111 (62.0)

Cheeks 35 (18.2) 3 (23.1) 32 (17.9)

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Nose 23 (12.0) 0 (0) 23 (12.8)

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Lower limbs 135 (70.3) 6 (46.2) 129 (72.0)

Upper limbs 99 (51.6) 4 (30.8) 95 (53.1)

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Trunk 51 (26.6) 1 (7.7) 50 (27.9)

Data are number of patients (%).

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Table 3. Autoantibodies in patients with levamisole-induced vasculopathy

Autoantibodies All patients Group 1 Group 2 p

<0.
ANCAs 167/178 (93.9)
7/9 (77.8) 160/169 (94.7) 05

Indirect immunofluorescence:

pANCAs only 99/167 (59.3) 4/7 (57.2) 95/158 (60.1) ns

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<0.
cANCAs only 5/167 (3)

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2/7 (28.6) 3/158 (1.9) 05

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pANCAs and cANCAs 30/167 (18) 0/9 (0) 30/158 (19.9) ns

xANCAs 7/167 (4.2) 0/9 (0) 7/158 (4.4) ns

ELISA

Anti-MPO Abs only

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38/118 (32.2) 1/2 (50) 37/116 (31.9)
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Anti-PR3 Abs only 18/118 (15.3) 1/2 (50) 17/116 (14.7) ns

Anti-MPO and anti-PR3 Abs 51/118 (43.2) 0/2 (0) 51/116 (44) ns
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APL Abs 93/137 (67.9) 5/7 (71.4) 77/130 (59.2) ns

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Lupus anticoagulant 58/137 (42.3) 3/7 (42.9) 55/130(42.3) ns

Anti-cardiolipin Abs 64/137 (46.7) 2/7 (28.6) 62/130 (47.7) ns

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Anti-β2GP1 Abs 11/137 (8) 0/7 (0) 11/130 (8.5) ns

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ANA positivity or titers > 1/80 75/144 (52.1) 3/9 (33.3) 72/135 (53.3) ns

Abbreviations: Abs: antibodies; ANCAs: anti-neutrophil cytoplasmic antibodies; cANCAs:

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cytoplasmic ANCAs; xANCAs: atypical ANCAs; ELISA: enzyme-linked immunosorbent

assay; MPO: myeloperoxydase; pANCAs: perinuclear ANCAs; PR3: proteinase 3; APL:

anti-phospholipid; ANA: anti-nuclear antibodies

Data are number of patients (%).

ns: non-significant

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