Cutaneous Vasculopathy Associated with Levamisole-Adulterated Cocaine

We report a case of cutaneous vasculopathy associated with the use of levamisole-adulterated cocaine. This recently described clinical entity is characterized by a purpuric rash with a predilection for the ears, leukopenia, and anti-neutrophilic cytoplasmic antibody (ANCA) positivity. It is estimated that more than 70% of the current United States cocaine supply is contaminated with levamisole. Levamisole is a widely available, inexpensive, white powder used as a “cutting agent” in cocaine to expand volume and increase profits. It may also increase the euphoric and stimulatory effects of cocaine by increasing brain dopamine levels and producing amphetamine-like metabolites. Our patient exhibited a characteristic rash with involvement of the ears, leukopenia, and cocaine metabolites were detected in serum and urine. The presence of levamisole was confirmed in the urine utilizing gas chromatography-mass spectrometry. ANCA positivity was also present. Punch biopsy of the skin demonstrated vascular thrombosis and necrosis without true vasculitis. We review the literature for reported cases of cocaine-levamisole cutaneous vasculopathy syndrome, highlight the salient immunologic abnormalities, and contrast the features of this entity with idiopathic systemic vasculitis

Guillain–Barré Syndrome After Aortic, Tricuspid and Mitral Valve Surgery

Guillain-Barré syndrome (GBS) after surgery may be more common than previously recognized; however, GBS after open heart surgery is exceedingly rare. We describe a rare case of GBS occurring after aortic, tricuspid and mitral valve surgery and review the world’s literature. Vigilance for GBS among post-surgical patients is needed.</jats:p