Peer Reviewed


Levamisole Toxicity From Adulterated Cocaine

  • Authors:
    Carmen A. Julian, DO

    Chief Resident, Philadelphia College of Osteopathic Medicine (PCOM)/North Fulton Hospital Medical Campus Dermatology Residency, Roswell, Georgia, in affiliation with the Georgia Campus of PCOM

    Marcus B. Goodman, DO
    Dermatologist, Goodman Dermatology, PC, and Program Director, PCOM/North Fulton Hospital Medical Campus Dermatology Residency, Roswell, Georgia

    Julian CA, Goodman MB. Levamisole toxicity from adulterated cocaine. Consultant. 2019;59(1):22-24.


    A 40-year-old woman presented with fever, cough, hemoptysis, and an asymptomatic rash with purplish discoloration on her trunk, extremities, and ears.

    History. The patient reported that the rash had started 5 days prior while she had been undergoing inpatient treatment for pneumonia at a nearby hospital. The rash had started on day 2 of her admission. She denied pain, bleeding, or pruritus associated with the lesions and denied any constitutional symptoms. Empiric intravenous antibiotics had been given for community-acquired pneumonia on her previous admission. A punch biopsy had been performed at her recent outside admission, but our attempts to obtain a report were unsuccessful. No specific treatment for her rash had yet been implemented.

    The patient had left from the previous hospital against medical advice and presented to our hospital with worsening symptoms. Prior medical records, including the biopsy results and antibiotic treatment, again were unavailable. She reported tobacco abuse and cocaine use, most recently 11 days prior. She denied intravenous drug use.

    Physical examination. At presentation, the patient was nontoxic and afebrile, with stable vital signs. Skin examination revealed tender, violaceous macules and patches on the trunk, extremities, and ears (Figures 1-3). There were areas of retiform, stellate purpura progressing to bullae on the upper arms and lower legs. Additionally, there was a pink to erythematous maculopapular eruption on the entire back. A small eschar was present on the left medial ankle (Figure 4). No desquamation or mucosal involvement was noted. On the left outer arm, there was a healing, sutured punch-biopsy wound (Figure 5).

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    Figure 1.

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    Figure 2.

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    Figure 3.

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    Figure 4.

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    Figure 5.

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