Nina Tello, Jorge Alejandro Mateos-Parra and Alejandro Díaz-Borjon
Abstract Background: We present the case of a patient with vitiligo that was treated with levamisol and presented with pure levamisole induced vasculopathy. The patient had no cocaine use and immunologic findings persisted for more than 4 years after the consumption of the drug. Case Presentation: 70 year-old women with a history relevant for vitiligo. Shortly after initiating levamisole she developed extensive necrotic skin lesions, coagulopathy and thrombocytopenia. At the time she presented an hemorragic stroke that resulted in hemiparesia. Four months later, she presented with loss of consciousness and a mixed aphasia. A CT scan revealed the prior lesion only, an EEG showed abnormal activity. Her lab tests showed a positive lupus anticoagulant and p-ANCA. She was initially managed with phenytoin, levetiracetam and enoxaparin. She returned with a status epilepticus and was then managed with phenyotin, levetiracetam, and diazepam with no response. Considering a nonthrombotic manifestation of antiphospholipid syndrome methylprednisolone 1 gr per day for three doses were administered with improvement in language and motor function. She continued enoxaparin and prednisone with good results. Mycophenolate mofetil was later added to her treatment as a prednisone sparing agent. Lupus anticoagulant persists positive to this date. Conclusions: Vasculopathy presenting as skin necrosis or purpura is a feature of both cocaine and levamisole use. There are very few cases of levamisole only induced vasculitis and even less in the adult population. It is conventionally believed that the sole therapeutic intervention needed is avoidance of levamisol exposure. In this case, the persistence of lupus anticoagulant for more than 4 years, the neurologic symptoms upon steroid suspension and immediate response to bolus led to the decision of maintenance immunosupresive therapy and anticoagulation. There is a subset of patients who may develop an autoimmune disease and should be observed and treated for longer periods.