This case presents a rarely seen combination of two Cocaine-induced syndromes occurring simultaneously. Levamisole-adultered cocaine leads to Levamisole-induced Vasculitis (LIV), while cocaine’s vasoconstrictive effect causes destruction of the osteo-cartilaginous structures of nose called Cocaine-induced midline destructive lesions (CIMDL). This case raises awareness of a new pattern of recognition in order to avoid misdiagnosis. We present a case of a 51-year-old male cocaine user who developed severe left-sided ear pain and yellowish secretions with circular necrotic lesions in the nose, right earlobe, and dorsum of feet bilaterally. An extensive workup to assess purpuric lesions’ etiology, including vasculitis, collagen vasculitides, anti-phospholipid syndrome, hypercoagulable state and infectious process, was performed and found negative. He developed bilateral tympanic membrane perforation and purpuric necrotic skin lesions, at the same time, due to CIMDL and LIV, respectively. These two syndromes rarely present simultaneously in a patient. This case report exhibits a new Cocaine-induced clinical presentation that will help hospitalists recognize the disease and avoid misdiagnosis leading to unnecessary tests, prolonged hospitalization, and higher healthcare costs. Diagnosis is challenging, as it consists of establishing a temporal relationship between cocaine ingestion and symptoms’ onset. This disease usually has a benign progression because symptoms frequently resolve without intervention.
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