Abstract: PUB517
An Unkind Cut: A Case of Pauci-Immune Crescentic Glomerulonephritis Associated with Suspected Exposure to Levamisole-Adulterated Cocaine
Session Information
Category: Glomerular
- 1005 Clinical Glomerular Disorders
Authors
- Lorch, Robert, Baylor College of Medicine, Houston, Texas, United States
- Mclaughlin, Susanne Francis, None, Bellaire, Texas, United States
- Mandayam, Sreedhar A., Baylor College of Medicine, Houston, Texas, United States
Background
Levamisole (LEV) is a ubiquitous cocaine adulterant in the United States and has been implicated in an ANCA-associated vasculitis syndrome which commonly manifests as purpuric skin lesions, agranulocytosis, and thrombocytopenia. An increasingly recognized effect of LEV is kidney injury in the form of pauci-immune glomerulonephritis (GN). Our understanding of LEV-induced kidney injury is limited, and it can be difficult to differentiate ANCA-associated GN secondary to LEV from primary ANCA-associated vasculitis based on serology and biopsy. The implications for prognosis and treatment in this scenario are unclear.
Methods
We present the case of a 57-year-old man with stage 3 CKD and an approximately 20-year history of regular intranasal cocaine use, who presented with 8 weeks of myalgias and chills, as well as several days of new-onset dyspnea. He had last used cocaine 2 days prior. Physical exam was remarkable only for bibasilar crackles and bilateral scattered rhonchi in the lungs, mild abdominal distension, and no abnormal skin findings. Initial laboratory testing revealed a creatinine of 5.1 mg/dL (baseline creatinine of approximately 2 mg/dL), blood urea nitrogen of 66 mg/dL, and urine testing positive for cocaine. Bilateral patchy airspace opacities were seen on chest CT. Renal biopsy demonstrated pauci-immune crescentic GN, and serologic testing was suggestive of microscopic polyangiitis (anti-MPO positive, anti-PR3 negative). Due to his significant history of cocaine use, LEV-induced vasculitis could not be ruled out as a cause of rapidly progressive GN. He was treated with corticosteroids, rituximab, and plasma exchange; although he ultimately progressed to dialysis-dependent renal failure.
Conclusion
Up to 80% of cocaine in the United States now contains LEV, and this case highlights the growing public health concern of LEV exposure. Our current knowledge of the clinical, laboratory, and biopsy findings specific for LEV-induced GN is often too limited to differentiate this form of drug-induced vasculitis from primary vasculitis, especially in otherwise medically complicated cases and when clinical stakes are high. A better understanding of the effects of LEV on the kidney is needed so that improved methods to diagnose and treat levamisole-induced glomerulonephritis may be developed.