brand logo

Am Fam Physician. 2016;93(1):57-58

Author disclosure: No relevant financial affiliations.

A 41-year-old woman presented to the emergency department with leg ulcers and ecchymoses on her ears that began to develop one month prior. The leg ulcers began as painful, fluid-filled blisters and evolved into ulcers with a black crust. The lesions had appeared and resolved several times over the previous three years, but she did not seek medical attention. She took prednisone intermittently for psoriasis and had a long history of cocaine abuse.

Physical examination showed multiple ulcerated lesions on the anterior aspect of both lower extremities (Figure 1) and multiple tender purpuric lesions on both ears (Figure 2). The examination showed psoriatic plaques on her legs, elbows, and fingers. Her vital signs were normal. A complete blood count, comprehensive metabolic panel, and coagulation laboratory test results were normal. Urine toxicology testing was positive for cocaine. She had an elevated C-reactive protein level (96.3 mg per L [917.16 nmol per L]) and erythrocyte sedimentation rate (48 mm per hour).

Question

Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

Discussion

The answer is A: levamisole-induced vasculitis. A skin biopsy showed a leukocytoclastic vasculitis consistent with levamisole-induced vasculitis. Levamisole is an antihelminth drug that was used as an antineoplastic agent, but adverse effects such as agranulocytosis and an ulcer-causing vasculopathy have now limited its use to veterinary medicine. It is commonly used to lace cocaine because of its psychoactive effects. It is estimated that 70% of cocaine in the United States contains levamisole.1,2

The lesions associated with levamisole exposure are most commonly purpura on the ears, nose, and cheeks. Skin ulcers with a hemorrhagic base may also occur. These lesions usually resolve spontaneously within a few weeks of discontinuing the drug, but can recur with subsequent exposure.24

Necrobiosis lipoidica diabeticorum occurs in patients with diabetes mellitus or a strong family history of the disease. It is characterized by single or multiple asymptomatic red to yellow, shiny plaques that gradually enlarge and contain dermal blood vessels. Ulceration of the plaques is common and can occur with or without trauma. The pathogenesis is unknown, but biopsy can confirm the diagnosis.5

Pyoderma gangrenosum is an idiopathic condition associated with inflammatory bowel disease, arthritis, joint inflammation, and malignancy. It is characterized by painful pustules and rapidly progressive ulcers with violaceous undermined borders, surrounding erythema, and a purulent base. The pathogenesis is believed to be related to neutrophil dysfunction. It is a diagnosis of exclusion.5

Bacteria and pus from vegetations on an infected heart valve may cause septic emboli. They travel via the bloodstream and can cause the sudden development of painful, purpuric skin ulcers. They are associated with other systemic signs of bacteremia, including fever, malaise, myalgias, arthralgia, and elevated white blood cell count.6,7

Wegener granulomatosis is a small to medium vessel autoimmune vasculitis that is characterized by skin, lung, and kidney involvement. Skin findings include necrotic ulcers, palpable purpura, and digital infarcts. Patients with this condition have lung nodules, upper respiratory tract disease, and segmental necrotizing glomerulonephritis.5,7

ConditionCauseCharacteristics
Levamisole-induced vasculitisLevamisole exposurePurpura on the ears, nose, cheeks; skin ulcers with a hemorrhagic base
Necrobiosis lipoidica diabeticorumUnknown but associated with diabetes mellitusSingle or multiple asymptomatic red to yellow, shiny plaques; gradual enlargement and possible ulceration
Pyoderma gangrenosumNeutrophil dysfunctionPainful pustules and rapidly progressive ulcers with violaceous undermined borders, surrounding erythema, and a purulent base
Septic emboliHeart valve infectionSudden development of painful, purpuric skin ulcers; other systemic signs of bacteremia
Wegener granulomatosisAutoimmune vasculitisNecrotic ulcers, palpable purpura, digital infarcts; skin, lung, and kidney involvement

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at https://www.aafp.org/afp/photoquizinfo. To be considered for publication, submissions must meet these guidelines. Email submissions to afpphoto@aafp.org.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

A collection of Photo Quiz published in AFP is available at https://www.aafp.org/afp/photoquiz

Continue Reading


More in AFP

More in PubMed

Copyright © 2016 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions for copyright questions and/or permission requests.