Leukocytoclastic Vasculitis with Fibrin Thrombi secondary to Levamisole

Purpose: To present a case study involving an atypical presentation of a purpuric non-blanchable discolored skin lesion and how a diagnosis of Vasculitis secondary to Levamisole (leukocytoclastic vasculitis with fibrin thrombi) was made.

Rationale: 47 year old female presenting to an emergency room with a 3 day history of worsening well-defined purpuric painful skin lesion of the left hip and buttocks region. Presentation was atypical in nature, with demarcated edges of intact purpuric non-blanchable erythema with blistering and pain in an ambulatory female with no history of trauma, pressure or fall. Toxicology screen was positive for cocaine with no other significant past medical history. Differential diagnosis included deep tissue injury, cellulitis, necrotizing fasciitis, coumadin necrosis, calciphylaxis and pyoderma gangrenosum. Determining a cause of the skin lesion was required to direct the management and treatment and ultimate healing of the ulceration.

Problem: Limited knowledge of levamisole and the dangers of its presence as an additive in cocaine and how it can present as unexplained ulcerations.

Management: Tissue biopsy revealed Leukocytoclastic Vasculitis with Fibrin Thrombi, confirming a diagnosis of Vasculitis secondary to levamisole. Ulceration was managed with surgical debridement, negative pressure wound therapy and split-thickness skin graft, with complete healing of ulceration.

Conclusion: Atypical skin lesions among drug users, specifically cocaine, is a growing concern among the wound care community and the need to think outside the box for other causes of presentation for patients presenting with purple discolored skin lesions needs to be considered. Wound care nurses are typically consulted for these type of skin lesions and having the knowledge that levamisole and cocaine drug use is a possibility in the differential diagnosis, will assist the medical team in quicker diagnosis and proper treatment modalities.