Introduction: Cocaine-induced pulmonary injury patterns include thermal airway trauma, eosinophilic pneumonitis, barotrauma causing pneumothorax, ischemia due to vasospasm and diffuse alveolar hemorrhage (DAH) with hemorrhagic alveolitis. Levamisole, an immunomodulatory anti-helminthic agent, is frequently used as an adulterant in cocaine due to its amphetamine-like stimulant effect. Levamisole can cause purpuric cutaneous vasculitis lesions that may be associated with perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA). We present a case of DAH with p-ANCA positivity due to levamisole-cocaine inhalation. Description: A 35 y-o man was admitted after crack cocaine use. He was hypoxemic and was intubated. He was noted to have purpuric raised lesions on forearms, wrists and forehead. Chest imaging showed bilateral alveolar and ground glass infiltrates. Following intubation, he was noted to have copious bright red bloody secretions in the endotracheal tube. Bronchoscopy was performed that demonstrated blood-tinged secretions in the tracheobronchial tree and lower airways bilaterally. Bronchoalveolar lavage (BAL) had increasing bloody return in sequential aliquots in multiple bronchopulmonary segments bilaterally. BAL cytology showed neutrophil-predominant acute inflammatory cells. Diagnostic studies showed WBC 16 k/cumm, Sed rate 19, negative infectious workup and normal echocardiography. Serology was positive for p-ANCA 1:1280 but negative for c-ANCA, MPO, anti-GBM, ANA, Anti-dsDNA, HIV and hepatitis B/C. Renal function was normal. He received intravenous pulse-dose methylprednisolone (1 gm/day) for 3 days with substantial improvement in chest radiography. Hemorrhagic tracheobronchial secretions resolved, and he had no further hemoptysis following extubation. Discussion: Adulteration of cocaine with levamisole is increasingly reported and is associated predominantly with cutaneous lesions. Levamisole induces interferon synthesis and neutrophil extracellular traps (NETs) that cause p-ANCA vasculitis, agranulocytosis and purpura. It can mimic vasculitic pulmonary-renal syndromes due to positive p-ANCA serology. Our case highlights the differentiation of drug induced immune responses and treatment with possibly short courses of pulse-dose steroids without long term immune suppression in such cases.
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