Natasha Purai Arora

Levamisole-induced leukocytoclastic vasculitis and neutropenia in a patient with cocaine use: An extensive case with necrosis of skin, soft tissue, and cartilage

Levamisole-induced vasculitis is a relatively new entity in people who use cocaine. We describe a 44-year-old woman with a history of cocaine use who presented with a complaint of a painful rash of 2-3 month’s duration on her extremities, cheeks, nose, and earlobes. She had not experienced fever, weight loss, alopecia, dry eyes, oral ulcers, photosensitivity, or arthralgia. Examination revealed tender purpuric eruptions with central necrosis on her nose, cheeks, earlobes, and extremities. Laboratory investigations revealed neutropenia, an elevated erythrocyte sedimentation rate (ESR), presence of lupus anticoagulant, low complement component 3 (C3), and presence of perinuclear anti-neutrophil cytoplasmic antibody (p-ANCA). A urine toxicology screen was positive for cocaine, and gas chromatography–mass spectrometry was positive for levamisole. Skin biopsy showed leukocytoclastic vasculitis and small vessel thrombosis. Necrotic lesions of the nose led to its self-amputation. Large bullae on the lower extremities ruptured, leading to wound infection and extensive necrosis that required multiple surgical debridements. When necrosis progressed despite debridement, bilateral above-knee amputation of the legs was performed. Once new lesions stopped appearing, the patient was discharged home. Two months later, she had a recurrence related to cocaine use. To the best of our knowledge, this is only the second reported case of levamisole-induced vasculitis that required above-knee amputation.

Usefulness of intravenous lipid emulsion for cardiac toxicity from cocaine overdose.

The investigators describe the clinical course of a 26-year-old-man who was brought to the emergency department in a comatose state with status epilepticus after smoking a large amount of crack cocaine. In the emergency department, he was intubated because of depressed mental status and respiratory acidosis. His troponin I remained negative, and electrocardiography showed wide-complex tachycardia with a prolonged corrected QT interval. Because of the corrected QT interval prolongation and wide-complex tachycardia, the patient was started on intravenous magnesium sulfate and sodium bicarbonate. Despite these interventions, no improvement in cardiac rhythm was observed, and electrocardiography continued to show wide-complex tachycardia. The patient became more unstable from a cardiovascular standpoint, with a decrease in blood pressure to 85/60 mm Hg. He was then given 100 ml of 20% lipid emulsion (Intralipid). Within 10 minutes of starting the infusion of 20% lipid emulsion, wide-complex tachycardia disappeared, with an improvement in systemic blood pressure to 120/70 mm Hg. Repeat electrocardiography after the infusion of intravenous lipid emulsion showed regular sinus rhythm with normal QRS and corrected QT intervals. The patient was successfully extubated on day 8 of hospitalization and discharged home on day 10. His cardiac rhythm and blood pressure remained stable throughout his further stay in the hospital.

Cutaneous Vasculopathy and Neutropenia Associated With Levamisole-Adulterated Cocaine

Background:Levamisole has recently been implicated as a cause of cutaneous vasculopathy in cocaine abusers. The objective of this study was to describe this relatively new entity by reviewing published cases identified through a literature search. Methods:Published reports identified through a search of PubMed database (from 1964 to November 2011) were reviewed to record clinical, serological and pathologic findings. Results:A cohort of 32 patients had a mean age of 44 ± 9 years with a female predominance (75%). Rash predominately affected lower extremities (87.5%), followed by face (78%) and ears (69%) and typically presented as purpuric plaques, which were seen in a retiform pattern in 16 (50%) and had central necrosis in 11 patients (34%). Leukopenia and neutropenia were found in 20 patients (63%). Antinuclear cytoplasmic antibody (ANCA) was positive in 30 patients (94%); p-ANCA in 28 patients (87.5%), c-ANCA in 19 (59%) and both in 17 patients (53%). Skin biopsy results were available for 29 patients: 14 (48%) had pure thrombotic vasculopathy, 4 (14%) had pure small vessel vasculitis and 11 (38%) had evidence of both. Treatment information was available for 30 patients. Only supportive care was given to 11 patients (37%), steroids to 16 (53%) and surgical treatment for 5 (17%). Clinical course of lesions was available for 24 patients. Rash resolved in 11 patients (46%) and improved in 13 (54%). During median follow-up of 21 days (range, 7–270 days), 10 of 22 patients had recurrences related to cocaine use. Conclusion:Levamisole-induced cutaneous vasculopathy in cocaine users is characterized by a female predominance, a retiform purpuric rash with a predilection for lower extremities, autoantibody production, leukopenia and/or neutropenia and recurrences with future cocaine use.

Iron deficiency anemia in heart failure

Anemia and iron deficiency are quite prevalent in patients with heart failure (HF) and may overlap. Both anemia and iron deficiency are associated with worse symptoms and adverse clinical outcomes. In the past few years, there has been an enormous interest in the subject of iron deficiency and its management in patients with HF. In this review, the etiology and relevance of iron deficiency, iron metabolism in the setting of HF, studies on iron supplementation in patients with HF and potential cardiovascular effects of subclinical iron overload are discussed.

Cardiac Magnetic Resonance Imaging in Peripartum Cardiomyopathy

Background:Peripartum cardiomyopathy (PPCM) is a rare life-threatening condition of unclear etiology. Data on the use of cardiac magnetic resonance (CMR) imaging to characterize PPCM are limited. This study was done to assess the role of CMR imaging for the diagnosis and prognostication of patients with PPCM. Methods:Medical records of a tertiary medical center were screened for PPCM patients with CMR imaging done within the past 5 years (2006–2011). Images were reviewed by 2 expert radiologists (blinded to clinical data) using cine sequences for chamber function and size, T2-weighted images for the determination of edema (T2-ratio), and late gadolinium enhancement (LGE) sequences for myocardial tissue characterization. Results:Ten PPCM patients (aged 28 ± 6 years, 90% African American) had a total of 15 CMR examinations: 4 in the acute phase (within 7 days of diagnosis) and 11 during follow-up (median, 12 months; range, 1–72 months). Left ventricular ejection fraction was decreased in all 4 initial scans. Elevated T2 ratio (>2) seen in 1 patient decreased on follow-up imaging. LGE was seen in 1 of the 4 acute-phase scans and in 4 of the 11 follow-up phase scans. These 4 patients had multiple readmissions because of heart failure exacerbations and persistently low left ventricular ejection fraction on subsequent echocardiograms. Conclusions:LGE seems to be associated with a poor prognosis in the setting of PPCM. CMR imaging seems to have promising practical implications in the diagnosis and prognostication of PPCM patients.

Anemia and iron deficiency in heart failure.

Anemia is a common comorbidity in patients with heart failure (HF) and is associated with poor prognosis. Iron deficiency, with or without anemia, confers increased risk of mortality and morbidity. Along with the altered iron metabolism in HF patients, inflammation creates challenges in the interpretation of laboratory parameters used to diagnose anemia in HF. Since the RED-HF trial failed to demonstrate any benefit from the use of erythropoiesis-stimulating agents (ESAs) on mortality or morbidity in HF patients, ESAs are no longer considered a treatment option, although intravenous iron has potential as therapy for anemic and nonanemic HF patients.

Impact of Interhospital Transport on the Physiologic Status of Very Low-Birth-Weight Infants

OBJECTIVES To evaluate the change in physiologic stability of very low-birth-weight (VLBW) infants following transport using TRIPS (transport risk index of physiologic stability) score as a measure of physiologic stability and compare changes in TRIPS score in groups of VLBW infants who underwent shorter versus longer transport. STUDY DESIGN Retrospective chart review. RESULTS Our cohort of 106 infants, 44 (41%) of whom were females, had a mean birth weight of 777 g (standard deviation [SD] 159) and median gestational age of 26 weeks (range 23 to 32 weeks). Mean weight at transfer was 1,610 g (SD 924) and mean postnatal age at transfer was 56 days (SD 45). Median time on transport was 15 minutes (range 10 to 85 minutes). All 106 transports were ground transports. Of the 106 infants, 57 (54%) had deterioration, 20 (19%) had improvement, and 29 (27%) had no change in their physiologic status during transport. Comparison of the two transport duration groups based on median transport time as a cutoff point (i.e., ≤ 15 minutes and > 15 minutes) revealed a higher proportion of infants with deterioration in their physiologic status in the prolonged transport (>15 minutes) group (65% versus 45%; p = 0.03). Temperature change, either alone or in combination with other indices, was responsible for change in TRIPS score (deterioration or improvement) in 79% of these infants. CONCLUSIONS Interhospital transport of VLBW infants may cause deterioration in their physiologic status, the likelihood of which is increased with longer duration of transport. Better temperature regulation during interhospital transport may decrease the chances of deterioration in physiologic status of VLBW infants.

Role of Non-High-Density Lipoprotein Cholesterol in Predicting Cerebrovascular Events in Patients Following Myocardial Infarction

Although there appears to be a role for statins in reducing cerebrovascular events, the exact role of different lipid fractions in the etiopathogenesis of cerebrovascular disease (CVD) is not well understood. A secondary analysis of data collected for the placebo arm (n = 2,078) of the Cholesterol and Recurrent Events (CARE) trial was performed. The CARE trial was a placebo-controlled trial aimed at testing the effect of pravastatin on patients after myocardial infarction. Patients with histories of CVD were excluded from the study. A Cox proportional-hazards model was used to evaluate the association between plausible risk factors (including lipid fractions) and risk for first incident CVD in patients after myocardial infarction. At the end of 5 years, 123 patients (6%) had incident CVD after myocardial infarction (76 with stroke and 47 with transient ischemic attack). Baseline non-high-density lipoprotein (HDL) cholesterol level emerged as the only significant lipid risk factor that predicted CVD; low-density lipoprotein cholesterol and HDL cholesterol were not significant. The adjusted hazard ratios (adjusted for age, gender, hypertension, diabetes mellitus, and smoking) for CVD were 1.28 (95% confidence interval [CI] 1.06 to 1.53) for non-HDL cholesterol, 1.14 (95% CI 0.96 to 1.37) for low-density lipoprotein cholesterol, and 0.90 (95% CI 0.75 to 1.09) for HDL cholesterol (per unit SD change of lipid fractions). This relation held true regardless of the level of triglycerides. After adjustment for age and gender, the hazard ratio for the highest natural quartile of non-HDL was 1.76 (95% CI 1.05 to 2.54), compared to 1.36 (95% CI 0.89 to 1.90) for low-density lipoprotein cholesterol. In conclusion, non-HDL cholesterol is the strongest predictor among the lipid risk factors of incident CVD in patients with established coronary heart disease.

Purulent Pericardial Effusion From Community-Acquired Methicillin-Resistant Staphylococcus aureus

Abstract: Although the incidence of purulent pericarditis has decreased significantly in the modern antibiotic era, a high index of clinical suspicion should be maintained to diagnose this life-threatening illness at an early stage. Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is a global pathogen and notorious for its ability to cause infection in otherwise healthy individuals. However, it has been associated with purulent pericarditis only in some sporadic case reports. The authors describe a case of purulent pericardial effusion caused by CA-MRSA infection. To the best of our knowledge, this is only the fourth case of CA-MRSA pericarditis to be reported in English literature.

Coccidioidomycosis masquerading as malignancy.

Skeletal coccidioidomycosis is extremely rare and in the non-endemic areas, diagnosis is often delayed or missed resulting in extensive and unnecessary medical investigation for other diseases. The authors report a case of disseminated skeletal coccidioidomycosis in a previously healthy person living in a non-endemic area, who was initially thought to have a malignancy. Due to the presence of multiple expansile lytic bone lesions on x-rays and CT scan, an extensive investigation for malignancy was done. Diagnosis of coccidioidomycosis was made when H&E and Gomori’s methenamine silver staining of a bone biopsy sample revealed multiple fungal spherules, which were confirmed to be Coccidioides immitis by culture and PCR. On questioning, the patient admitted to have spent 2 weeks in Arizona (an endemic area) few months ago. He was discharged home on long-term fluconazole. At 1 month clinical follow-up, a significant improvement in his lesions was noticed.