scholarly journals Levamisole/Cocaine Induced Systemic Vasculitis and Immune Complex Glomerulonephritis

2015 ◽  
Vol 2015 ◽  
pp. 1-5 ◽  
Author(s):  
Lohit Garg ◽  
Sagar Gupta ◽  
Abhishek Swami ◽  
Ping Zhang
Keyword(s):  
Immune Complex ◽  
Systemic Vasculitis ◽  
Renal Involvement ◽  
Morphological Properties ◽  
High Dose ◽  
Cocaine Use ◽  
Immune Mediated ◽  
History Of ◽  
Psychotropic Effects ◽  
Complex Deposition

Levamisole is an antihelminthic and immunomodulator medication that was banned by the USFDA in 1998. It has been increasingly used to adulterate cocaine due to its psychotropic effects and morphological properties. Adverse reactions including cutaneous vasculitis, thrombocytopenia, and agranulocytosis have been well described. Despite systemic vasculitis in this setting, renal involvement is uncommon. We report here a case of ANCA positive systemic vasculitis with biopsy proven immune complex mediated glomerulonephritis likely secondary to levamisole/cocaine. A 40-year-old Caucasian male with no past medical history presented with 3-week history of fatigue, skin rash, joint pains, painful oral lesions, oliguria, hematuria, worsening dyspnea on exertion, and progressive lower extremity edema. He had a history of regular tobacco and cocaine use. Lab testing revealed severe anemia, marked azotemia, deranged electrolytes, and 4.7 gm proteinuria. Rheumatologic testing revealed hypocomplementemia, borderline ANA, myeloperoxidase antibody, and positive atypical p-ANCA. Infectious and other autoimmune workup was negative. Kidney biopsy was consistent with immune mediated glomerulonephritis and showed mesangial proliferation and immune complex deposition consisting of IgG, IgM, and complement. High dose corticosteroids and discontinuing cocaine use resulted in marked improvement in rash, mucocutaneous lesions, and arthritis. There was no renal recovery and he remained hemodialysis dependent.

scholarly journals ACUTE HEMICEREBELLITIS IN ADULTS: LITERATURE REVIEW AND PERSONAL OBSERVATION

2019 ◽  
Vol 26 (1) ◽  
pp. 68-73
Author(s):  
Alina V. Kupaeva ◽  
Evgenia A. Skornyakova ◽  
Leonid G. Zaslavskii
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Clinical Status ◽  
Epileptic Seizures ◽  
High Dose ◽  
Basic Therapy ◽  
Acute Cerebellitis ◽  
Immune Mediated ◽  
Bowel Diseases ◽  
History Of

Acute cerebellitis is a common inflammatory syndrome typically occurring in children and only on very rare occasions in adults. Thus, there was no description of acute cerebellitis, associated with Crohn’s disease, found in Russian sources of literature. We reported a case of acute cerebellitis in 45-year-old woman with a long history of Crohn’s disease treated with Mesalazine as a basic therapy and a resection of ileotransversoanastomosis together with small intestine two months before the onset of neurological symptoms. She first presented with severe headache and left-sided cerebellar dysfunction. The MRI showed signs of pronounced edema of the left hemisphere of the cerebellum, pial Gd-enhancement along the cerebellar folia, difficulty of CSF- flow. The application of lumbar puncture was impeded by the possibility of complications, such as brain herniation. Treatment with high-dose intravenous Methylprednisolone resulted in clinical and radiological improvement. Over the following year, her clinical status remained unchanged, except for one case of epileptic seizures as a result of switching of basic therapy of Crohn’s disease on Adalimumab. In this case, hemicerebellitis most likely has an immune-mediated nature. The temporal relationship with increased activity of Crohn’s disease and a significant positive response to corticosteroid therapy favored this hypothesis. It was known that inflammatory bowel diseases (IBD) had many extra-intestinal manifestations including neurological ones. With regard to that, the alterations in gut microbiota could be a possible common base for systemic inflammatory and autoimmune diseases, such as Crohn’s disease or autoimmune cerebellitis, described in this study.

The kidney in systemic vasculitis

2020 ◽  
pp. 4988-5001
Author(s):  
David Jayne
Keyword(s):  
Renal Disease ◽  
Immune Complex ◽  
Systemic Vasculitis ◽  
Disease Process ◽  
Rapid Progression ◽  
Inflammatory Disorder ◽  
Chronic Inflammatory Disorder ◽  
Anca Associated Vasculitis ◽  
Primary Systemic Vasculitis ◽  
Complex Deposition

Systemic vasculitis can occur as a primary autoimmune disorder, or as a secondary manifestation of another disease process (related to infection, malignancy, chronic inflammatory disorder, or drugs). Primary systemic vasculitis is classified according to the predominant size of the blood vessel involved and the presence of circulating antineutrophil cytoplasm autoantibodies (ANCA). Incidence and prevalence rates are between 15 and 20 per million and 200 to 400 per million population, respectively. Vasculitic syndromes frequently involve the kidney, causing tissue infarction, loss of function, and rapid progression to endstage renal disease within weeks or months. They account for 5% of cases of endstage renal failure. ANCA-associated vasculitis is the most common cause of renal vasculitis and has been the focus for most research. Management aims for an early diagnosis, recovery of renal function, and prevention of renal relapse. Small-vessel vasculitides—renal disease is common. There are two subgroups: ANCA-associated vasculitis that comprises three syndromes: granulomatosis with polyangiitis (formerly Wegener’s granulomatosis), microscopic polyangiitis, and eosinophilic granulomatosis with angiitis (formerly Churg–Strauss syndrome). The second subgroup is immune complex vasculitis and comprises IgA vasculitis (formerly Henoch–Schönlein purpura), antiglomerular basement membrane disease, and cryoglobulinaemia: these are ANCA negative and characterized by immune complex deposition. Medium- and larger-vessel vasculitides—renal disease is uncommon in the medium-vessel disorders polyarteritis nodosa (ANCA negative) and Kawasaki’s disease, and rare in the large-vessel disorders, giant cell arteritis and Takayasu’s arteritis. This chapter discusses the aetiology and pathogenesis, pathology, clinical presentation, diagnosis, management, disease relapse, and prognosis of systemic vasculitis in detail.

Immune-mediated tubulointerstitial nephritis

2018 ◽  
Author(s):  
Liviu Segall ◽  
Adrian Covic
Keyword(s):  
Immune Complex ◽  
Lupus Erythematosus ◽  
Interstitial Fibrosis ◽  
Tubular Atrophy ◽  
Immunoglobulin G4 ◽  
Immune Mediated ◽  
Inflammatory Bowel ◽  
Complex Deposition ◽  
Stage Renal Disease ◽  
End Stage

Immune-mediated tubulointerstitial nephritides (TINs) are generally encountered in the context of systemic or extrarenal autoimmune diseases, such as sarcoidosis, Sjögren syndrome, systemic lupus erythematosus, inflammatory bowel disease, TIN and uveitis (TINU) syndrome, and immunoglobulin G4-related disease. The pathogenesis of these TINs is complex and more or less unclear; it usually involves leucocyte activation, autoantibodies, immune complex deposition, complement activation, and release of inflammatory cytokines and growth factors. Tubulointerstitial inflammation most commonly has a chronic pattern, although acute forms of TIN may also occur. Furthermore, inflammation may be granulomatous (as in sarcoidosis or Crohn’s disease) or non-granulomatous. Immunofluorescence staining can sometimes reveal immune complex deposits and even antitubular basement membrane autoantibodies. Systemic immunosuppressive therapies are almost always required to prevent progression to irreversible interstitial fibrosis, tubular atrophy, and end-stage renal disease.

scholarly journals Prominent gallbladder enlargement: Kawasaki disease or other congenital or acquired gallbladder disease? A case report

2021 ◽  
Vol 49 (9) ◽  
pp. 030006052110415
Author(s):  
Liang Zhao ◽  
Yimin Hua ◽  
Kaiyu Zhou
Keyword(s):  
Abdominal Pain ◽  
Kawasaki Disease ◽  
Systemic Vasculitis ◽  
Gallbladder Disease ◽  
Clinical Manifestations ◽  
Acute Stage ◽  
High Dose ◽  
Glucocorticoid Treatment ◽  
Intravenous Immunoglobulin Therapy ◽  
History Of

Kawasaki disease (KD) is a common systemic vasculitis in childhood that can result in damage to multiple body systems. However, prominent gallbladder (GB) enlargement in the acute stage is especially rare. A 5-year-old boy was admitted to the hospital with an 8-day history of a cervical mass, 7-day history of fever, and 5-day history of abdominal pain and rash. The child was diagnosed with KD. After treatment with high-dose intravenous immunoglobulin therapy (2 g/kg), all clinical manifestations were relieved except the abdominal pain. Enhanced computed tomography showed distinct enlargement of the GB, and a congenital choledochal cyst was strongly suspected. After high-dose glucocorticoid treatment, his obviously enlarged GB returned to normal size in the subacute phase. No abnormality was found during 2 years of follow-up. Prominent GB enlargement may emerge in the acute stage of KD. The enlarged GB can return to normal size within the subacute stage by standard treatment for KD. Proper diagnosis, thorough differential diagnosis, and active anti-inflammatory treatment of KD are crucial to avoid surgery.

scholarly journals Unusual case of levamisole-induced dual-positive ANCA vasculitis and crescentic glomerulonephritis

2018 ◽  
pp. bcr-2018-225913 ◽  
Author(s):  
Dileep Kumar ◽  
Ibrahim Batal ◽  
Belinda Jim ◽  
Barbara Mendez ◽  
Kisra Anis
Keyword(s):  
Unusual Case ◽  
Crescentic Glomerulonephritis ◽  
Systemic Vasculitis ◽  
Renal Involvement ◽  
Kidney Injury ◽  
Anticardiolipin Antibodies ◽  
Proteinase 3 ◽  
Rheumatology Clinic ◽  
Pulse Dose ◽  
History Of

Cocaine adulterated levamisole is an increasingly reported cause of skin necrosis, arthralgia and systemic vasculitis, but renal involvement is uncommon. We present a case of a 40-year-old Hispanic man with a history of cocaine abuse who presented with acute kidney injury to the rheumatology clinic where he was being treated for chronic inflammatory arthritis. He was found to have a serum creatinine of 2.5 mg/dL, microscopic haematuria and subnephrotic proteinuria, along with positive proteinase 3, myeloperoxidase, anticardiolipin antibodies and an elevated antinuclear antibody titre. The renal pathology revealed focal necrotising glomerulonephritis with crescentic features and mild immune type deposition. The patient was treated with cocaine abstinence, pulse dose steroids followed by maintenance prednisone, rituximab and cyclophosphamide. His renal function subsequently improved but did not normalise. We believe that his incomplete improvement was due to the degree of kidney injury on presentation as well as recidivism with cocaine use.

scholarly journals Hypokalemic Paralysis Secondary to Immune Checkpoint Inhibitor Therapy

2017 ◽  
Vol 2017 ◽  
pp. 1-4 ◽  
Author(s):  
Pragathi Balakrishna ◽  
Augusto Villegas
Keyword(s):  
Immune Checkpoint ◽  
Cytotoxic T Lymphocyte ◽  
Checkpoint Inhibitors ◽  
Kidney Injury ◽  
High Serum ◽  
Admission Diagnosis ◽  
High Dose ◽  
Immune Mediated ◽  
History Of ◽  
Checkpoint Inhibitor Therapy

Introduction of immune checkpoint inhibitors (ICIs) has led to significant improvements in the treatment of multiple malignancies. Anti-programmed cell death protein 1 (PD-1) and anti-cytotoxic T-lymphocyte antigen 4 (CTLA-4) are two essential ICIs that have been FDA approved since 2011. As the use of immunotherapy in melanoma and other malignancies increases, the potential of adverse events also increases. Overall, anti-PD-1 agents are well tolerated. In rare instances, colitis, endocrinopathies, skin, and renal toxicities have been observed. A 58-year-old male with a history of stage 4 cutaneous melanoma presented with quadriplegia while on nivolumab. Routine blood test revealed low potassium, low bicarbonate, and high serum creatinine. Admission diagnosis included hypokalemia, acute kidney injury, and renal tubal acidosis. The offending drug was discontinued, and the patient was started on high-dose corticosteroids. On discharge, paralysis was resolved. Renal function and potassium were normalized. Nivolumab was discontinued, and he was started on pembrolizumab. Literature suggests that, although rare, patients receiving ICE may develop immune-mediated nephritis and renal dysfunction. The mainstay of immune-related adverse event (irAE) management is immune suppression. Hence, given the increasing frequency of immunotherapy use, awareness should be raised in regard to irAEs and their appropriate management.

scholarly journals Levamisole-Adulterated Cocaine Induced Skin Necrosis of Nose, Ears, and Extremities: Case Report

2014 ◽  
Vol 5 (3) ◽  
pp. ar.2014.5.0101 ◽  
Author(s):  
Lauren A. Lawrence ◽  
Jose L. Jiron ◽  
Ho-Sheng Lin ◽  
Adam J. Folbe
Keyword(s):  
United States ◽  
Antiphospholipid Antibodies ◽  
Complete Resolution ◽  
Skin Necrosis ◽  
The United States ◽  
Antineutrophil Cytoplasmic Antibodies ◽  
Cocaine Use ◽  
Immune Mediated ◽  
The Face ◽  
History Of

Levamisole is an immunomodulatory and antihelminthic drug, previously removed from the United States market, and now estimated to be present in the vast majority of cocaine distributed in the United States. Levamisole-adulterated cocaine (LAC) exposure can result in neutropenia, thrombocytopenia, and vasculitis with a predilection for subsites of the face. The objective of this review is to increase awareness among otolaryngologists of the manifestations of LAC exposure. We present the case of a 33-year-old woman with a history of cocaine use, consulted for purpuric, necrotic lesions of the nose, cheeks, and ears, with accompanying leukopenia, thrombocytopenia, and positive antineutrophil cytoplasmic antibodies (ANCA). The effects of levamisole are immune mediated, with antibodies directed against neutrophils causing neutropenia, and vasculitis caused by antibody deposition or secondary to induction of antiphospholipid antibodies causing thrombosis. LAC exposure can be differentiated from other similar appearing pathologies by evaluating serology for specific ANCA. The most important treatment is cessation of cocaine use, which most often results in complete resolution of symptoms. Awareness of the presentation, complications, and treatment of LAC exposure may be especially important for otolaryngologists, who may be one of the firsts to evaluate an affected patient.

Abstract 16758: Unexplained Recurrent St-elevation Myocardial Infarction Complicated By Diffuse Alveolar Hemorrhage In Undiagnosed Granulomatosis With Polyangiitis

Circulation ◽  
2021 ◽  
Vol 144 (Suppl_2) ◽  
Author(s):  
Juthipong Benjanuwattra ◽  
Poemlarp Mekraksakit ◽  
Mahmoud Abdelnabi
Keyword(s):  
Chest Pain ◽  
Granulomatosis With Polyangiitis ◽  
Systemic Vasculitis ◽  
Renal Involvement ◽  
Diffuse Alveolar Hemorrhage ◽  
Alveolar Hemorrhage ◽  
Renal Functions ◽  
History Of ◽  
St Elevation ◽  
Work Up

Case Presentation: A 53-year-old man with a history of well-controlled hypertension and dyslipidemia presented with chest pain due to anterior STEMI for which a proximal LAD stent was placed. A week later, he presented with recurrent chest pain and ST elevation in the anterior chest leads. Coronary angiography showed in-stent thrombosis with heavy thrombus burden extending through the LAD. Manual thrombectomy with a second stent placement was done. He was discharged on triple therapy (aspirin, clopidogrel, and rivaroxaban), later, he presented to our medical facility with a 1-week history of hemoptysis. His clinical condition deteriorated requiring intubation. Laboratory work-up revealed elevated renal functions, proteinuria, and significant hematuria. CXR showed diffuse patchy opacities while CT chest was consistent with diffuse alveolar hemorrhage (Figure 1). Further work-up revealed elevated anti-proteinase 3 (c-ANCA) and low C4. Based on microscopic hematuria, renal impairment, and a positive c-ANCA, a diagnosis of granulomatosis with polyangiitis (GPA) was made. Induction with methylprednisolone, cyclophosphamide, and rituximab was initiated. His condition gradually improved, he was extubated successfully with marked improvement of renal functions. He was discharged on clopidogrel and scheduled for follow-up. Discussion: Few case reports have described STEMI as the initial presentation of GPA, likely attributed to vasculitis and accelerated atherosclerosis from systemic inflammation. Our patient had well-controlled cardiovascular risk factors and renal involvement with hematuria and elevated creatinine at the time of STEMI diagnosis, together with intermittent joint pains, suggesting ongoing systemic vasculitis. Clinicians should have a high index of suspicion for the possibility of non-atherosclerotic coronary stenosis as in cases of coronary vasculitis for early detection and management of a potentially reversible condition.

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