Pauci-immune glomerulonephritis in individuals with disease associated with levamisole-adulterated cocaine: a series of 4 cases

Abstract

Exposure to levamisole-adulterated cocaine can induce a distinct clinical syndrome characterized by retiform purpura and/or agranulocytosis accompanied by an unusual constellation of serologic abnormalities including antiphospholipid antibodies, lupus anticoagulants, and very high titers of antineutrophil cytoplasmic antibodies. Two recent case reports suggest that levamisole-adulterated cocaine may also lead to renal disease in the form of pauci-immune glomerulonephritis. To explore this possibility, we reviewed cases of pauci-immune glomerulonephritis between 2010 and 2012 at an inner city safety net hospital where the prevalence of levamisole in the cocaine supply is known to be high. We identified 3 female patients and 1 male patient who had biopsy-proven pauci-immune glomerulonephritis, used cocaine, and had serologic abnormalities characteristic of levamisole-induced autoimmunity. Each also had some other form of clinical disease known to be associated with levamisole, either neutropenia or cutaneous manifestations. One patient had diffuse alveolar hemorrhage. Three of the 4 patients were treated with short courses of prednisone and cyclophosphamide, 2 of whom experienced stable long-term improvement in their renal function despite ongoing cocaine use. The remaining 2 patients developed end-stage renal disease and became dialysis-dependent. This report supports emerging concern of more wide spread organ toxicity associated with the use of levamisole-adulterated cocaine.

FIGURE 1

Kidney biopsy histologic findings. A) Glomerulus from Case 1 with a large cellular crescent (methenamine silver-periodic acid-Schiff; 400x). B) Glomerulus from Case 1 showing fibrin (arrow) of a necrotizing lesion (trichrome; 400x). C) Medium power view of biopsy from Case 4 demonstrating a range of cellular to fibrocellular crescents. Features of mild interstitial fibrosis, tubular atrophy, and interstitial inflammation are also noted (periodic acid-Schiff; 100x). D) Glomerulus from Case 4 showing a small cellular crescent with associated fibrin of a necrotizing lesion (arrow) (hematoxylin & eosin; 400x).