Ischaemic skin lesions with multi-organ failure due to cocai
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A 33-year-old man without any medical history or treatments was admitted due to unconsciousness. Glasgow coma scale was 14 with drowsiness. Painless retiform purpura with central necrosis and blistering on the anterior faces of the thighs and on the left shoulder were observed. Two days before, he had snorted cocaine, smoked cannabis and drunk alcohol bought in France during a festival. He did not inject himself with any of the products and was not a user of injected drugs. He had an acute kidney injury (creatinine: 180 mol/L, urea: 5 mmol/L), rhabdomyolysis (CPK: 2,255 U/L), severe hepatic cytolysis (ASAT: 3,400 U/L, ALAT: 2,877 U/L) and hepatocellular dysfunction (prothrombin level: 64%, factor V level: 28%) without cholestasis.

Investigation for toxins in the blood and urine was positive for levamisole, cocaine and its metabolites, and tetrahydrocannabinol. Skin biopsy showed fibrinoid necrosis of the small vessel walls and intra-capillary thrombosis, but no vasculitis. In the hours after admission, he had renal tubular necrosis with rhabdomyosis and fulminant hepatic failure. Hepatic function normalized within five days after volume expansion and N-acetylcysteine administration. Creatinine returned to normal within three weeks. In contrast, skin necrosis worsened in spite of daily antiseptic care with silver sulfadiazine ointments. Three surgical excisions with one-week intervals, followed by skin grafts, achieved complete skin recovery within six weeks.

Levamisole induces painful retiform purpura. The ears and cheeks are primarily affected. Skin biopsies show thrombotic vasculopathy with or without vasculitis. Among the known predisposing factors for levamisole toxicity, only chronic and heavy exposure were reported for this patient.

The management of skin lesions is challenging. The use of steroids is debated. Other medical treatments have been tried, such as anticoagulants, cyclosporin and plasmapheresis. Large surgical resections are mandatory in most cases, followed by skin grafts that should be initiated after the limitation of necrosis (after about 10 days).

In conclusion, although rare, dermatologists should consider levamisole/cocaine intake among the classic causes of acute skin necrosis (vasculitis, autoimmune thrombosis and sepsis), especially in young patients.