Skin Necrosis Caused by Levamisole-Adulterated Cocaine

摘要

A 44-year-old man with a history of cocaine and heroin abuse was admitted to the ICU with features of altered mental status and blackish discoloration of the tip of the nose and bilateral pinnae (Figures 1-4). He was found to be in septic shock. According to the history provided by his wife, the patient was feeling unwell for the week before the admission but was unable to provide more specific details. The week before, he had used cocaine, which was cut with levamisole, and his nose and ear had progressively darkened to the current state of necrosis. The patient was initially managed with intravenous fluids and vasopressors. His chest radiograph and chest computed tomography scan showed multiple areas of probable septic emboli. The patient had positive antineutrophil cytoplasmic antibodies. Blood culture grew methicillin-resistant Staphylococcus aureus. Transesophageal echocardiography showed tricuspid vegetation. The patient was managed for septic shock with methicillin-resistant S. aureus with vancomycin and piperacillin/tazobactum. The nasal and ear necrosis were managed conservatively with daily dressing. The cause of nasal and ear necrosis was believed to be due to levamisole as there have been similar case reports in the past. When the patient was stabilized, he was transferred to the medical floors, but after 1 day, the patient left the hospital against medical advice and was lost to follow-up.