MINICASO  #  42  UNIVERSIDAD  DE  ANTIOQUIA  

Cuáles serían los diagnósticos presuntivos y el plan de estudio para este paciente?

Cuál es su diagnóstico?

Comentarios #16 JAIRO MESA COCK 25-12-2012 10:34 El falso negativo mas frecuente en la inmunofluorecen cia directa (dif) de las vasculitis, es el que depende del tiempo que se tarda en realizarla desde que empezó la vasculitis, ya que la duración de los anticuerpos en la pared de los vasos, es fugaz… de pocas horas jairo

Citar #15 JAIRO MESA COCK 25-12-2012 08:21 Diagnostic significance of immunofluoresce nt tests in dermatology]. Med Pregl. 2009 Nov-Dec;62(11-12):539-46. DIF test (…) Since there are false positive and negative results, DIF findings should be correlated with clinical histological and serological features. (…) DIF test is used for detection of different immunoreactanst s in leukocytoclasti c vasculitis jairo Citar #14 JAIRO MESA COCK 24-12-2012 09:11 Este caso de la Ude A, es bellísimo y una gran enseñanza… sólo quiero hacer una observación: el título… “seudovasculiti s”… porqué? Si lo que muestra la foto histológica, es una vasculitis: fibrina e infiltrado inflamatorio en la pared del vaso… si está informada la seudovasculitis por cocaina, también lo esta, la vasculitis*… además, en la caretelera de fotos de casos reportados que nos muestran los autores, marcadas con “G”, aparecen 3 fotos de la hematoxilina eosina y en una de ellas se ve la fibrina alrededor de un vaso… y marcadas con “H”, 2 fotos de la inmunofluoresce ncia positiva. * 2-Characteristi c purpura of the ears, vasculitis, and neutropenia--a potential public health epidemic associated with levamisole-adul terated cocaine J Am Acad Dermatol. 2011 Oct;65(4):722-5 . Abstract (…) Direct immunofluoresce nce studies suggested an immune complex-mediate d vasculitis. jairo Citar #13 JULIA INES MESA VILLEGAS 10-12-2012 19:36 Del artículo: Limited Cutaneous Vasculitis Associated With Levamisole-Adul terated Cocaine, J Clin Med Res, 2012;4(5):358-3 59, compartimos estas fotos por su gran similitud con el caso clínico que se presenta.

Citar #12 JAIRO MESA COCK 09-12-2012 16:49 La biopsia es de vasculitis leucocitoclásti ca… los exámenes pueden hacer pensar en lupus, más se conoce que la cocaina o el levamisol, con el que la adulteran pueden provocar todos los cambios anotados en el laboratorio del caso … faltó hacer los ANCA que siempre son positivos en los cuadros por cocaina adulterada… pero me parece QUE lo más llamativo ES el cuadro CLÍNICO purpúrico con necrosis de pabellones de las orejas descrito como muy típicos (ver fotos del Artículo Limited Cutaneous Vasculitis Associated With Levamisole-Adul terated Cocaine; J Clin Med Res • 2012;4(5):358-359.) 1-Cutaneous vasculopathy associated with cocaine use. Arthritis Care Res (Hoboken). 2011 Aug;63(8):1195- 202. doi: 10.1002/acr.20483. ABSTRAT Our patients most commonly presented with purpuric lesions and ulcers with areas of skin necrosis (…) Laboratory abnormalities included elevated inflammatory markers and positive perinuclear antineutrophil cytoplasmic antibodies (ANCAs) in all patients, and antimyeloperoxi dase antibodies in 7 of 8 patients. Cytoplasmic ANCA was positive in 5 of 8, equivocal in 2 of 8, and negative in 1 of 8 patients. Anti-proteinase 3 antibodies were found in 6 of 8 patients. Six of 8 patients had positive antinuclear antibodies and 5 of 8 had positive anti-double-str anded DNA antibodies (4 of 5 were at low titers). Two patients previously thought to have systemic lupus erythematosus (…). Lupus anticoagulant was positive in 3 of 8 and equivocal in 5 of 8. Anticardiolipin IgG was positive in 1 of 8 and IgM was positive in 6 of 8; β(2) -glycoprotein I IgM was positive in 2 of 8. Cold agglutinins were strongly positive in 6 of 6 patients in whom they were measured. Skin disease improved in 3 patients who appeared to have stopped using cocaine. It was chronic and progressive in 4 patients who continued to use cocaine, 2 of whom died presumably due to

multidrug overdose. (…) CONCLUSION: This report outlines clinical features and distinctive laboratory findings that, when present in the right clinical setting, should prompt consideration of cocaine-related cutaneous vasculopathy. 2-Characteristic purpura of the ears, vasculitis, and neutropenia--a potential public health epidemic associated with levamisole-adul terated cocaine J Am Acad Dermatol. 2011 Oct;65(4):722-5 . Abstract (…) Levamisole-indu ced vasculitis and neutropenia has been reported elsewhere in the United States and Canada. Up to 70% of cocaine in the United States could be contaminated. (…) We report 6 remarkably similar patients seen over just the past few months with retiform purpura on the body and tender purpuric eruptions, necrosis, and eschars of the ears after cocaine use in New York and California. All of these patients had positive perinuclear antineutrophil cytoplasmic antibody values and 3 of the 6 also had an associated neutropenia. Direct immunofluoresce nce studies suggested an immune complex-mediate d vasculitis. It appears the use of cocaine is associated with the peculiar clinical findings of ear purpura, retiform purpura of the trunk, and neutropenia. We believe this case series may represent the tip of the iceberg as a looming public health problem caused by levamisole. Although the direct causal relationship may be difficult to establish, the astute dermatologist or primary care physician should be able to recognize the characteristic skin lesions and should be wary of the potential development of agranulocytosis. Mil gracias a los colegas de la U de A… no conocía esta patología, hasta conocer éste caso jairo Citar #11 JAIRO MESA COCK 07-12-2012 12:36 Levamisole is a synthetic imidazothiazole derivative origi¬nally approved as an antihelminthic and subsequently used in the treatment of colon cancer, rheumatoid arthritis and pe¬diatric nephrotic syndrome. Recent reports link the use of levamisole-lace d cocaine to life-threatenin g agranulocytosis and to a distinctive form of necrotic purpura [1]. 1-Purpura, cutaneous necrosis, and antineutrophil cytoplasmic antibodies associated with levamisole-adul ter-ated cocaine. Arthritis Rheum. 2011;63(12):399 8-4001 Citar #10 JAIRO MESA COCK 07-12-2012 01:29 Limited cutaneous vasculitis associated with levamisole-adul terated cocaine. J Clin Med Res. 2012 Oct;4(5):358-9. Abstract Levamisole is among the many contaminants that have been detected in seized cocaine throughout North America and Europe. Little is known about the association between levamisole-adul terated cocaine and vasculitis. Herein we describe a case of limited cutaneous vasculitis manifested as retiform purpura and skin necrosis in a user of cocaine contaminated with levamisole. Citar #9 JAIRO MESA COCK 06-12-2012 01:21

Rheumatic manifestations of cocaine use. Curr Opin Rheumatol. 2013 Jan;25(1):50-5. Cocaine use is associated with several rheumatic syndromes. jairo Citar #8 JAIRO MESA COCK 05-12-2012 23:32 a no ser que los exámenes nos hagan pensar en otra cosa, por el momento sospecho que todo es por la cocaina, jairo Citar #7 JAIRO MESA COCK 05-12-2012 23:02 Levamisole-indu ced Wegener's granulomatosis following contaminated cocaine abuse. Skinmed. 2012 Jul-Aug;10(4):254-6. Abstract A 44-year-old woman with a medical history of chronic pain syndrome presented with (…) 7 weeks prior to admission and had a long-standing history of intranasal cocaine use. (…) Physical examination revealed centrally violaceous, tender, stellate, and retiform purpuric patches and plaques on her extremities, nasal dorsum, and cheeks. 1.0-centimeter tender purpuric nodules were noted on her bilateral second proximal interphalangeal joints. (…) further analysis showed a normal complement level, negative antinuclear antibody, human immunodeficienc y virus, rapid plasma reagin, and hepatitis panel. Trace cryoglobenemia and a positive anti-streptolys in O were noted, along with a positive antineutrophil cytoplasmic antibody (c-ANCA) (> 8.0 U) and perinuclear antineutrophil cytoplasmic antibodies, or p-ANCA (1.5 U). The hypercoagulable workup was negative. A skin biopsy taken from the left thigh was consistent with leukocytoclasti c vasculitis. (…) On follow-up, she admitted to frequent relapses of cocaine abuse and had developed tender purpuric plaques on her nose, ears, and extremities, some with ulcerations (…) Mass spectrometry analysis ofhair and urine samples tested positive for cocaine and levamisole. A presumptive diagnosis of levamisole-indu ced Wegener's vasculitis was made. She was restarted on high-dose prednisone and methotrexate with improvement and advised to discontinue cocaine use, so as to avoid exposure to both substances. jairo Citar #6 JAIRO MESA COCK 05-12-2012 22:07 Syndrome of cocaine-levamis ole-induced cutaneous vasculitis and immune-mediated leukopenia. Semin Arthritis Rheum. 2011 Dec;41(3):434-4 4. Epub 2011 Aug 24 We describe 4 patients who presented with palpable purpura, arthralgia or arthritis, leukopenia, and antineutrophil cytoplasmic antigen (ANCA) positivity most likely as a result of a hypersensitivit y reaction to cocaine-levamis ole induced vasculopathy.: CONCLUSIONS: Cocaine-levamis ole-related cutaneous vasculitis (…) a history of cocaine abuse who present with a tetrad of cutaneous manifestations consisting of palpable purpura or bullae with ear involvement (…) arthralgias, leukopenia, and positive ANCA jairo Citar

#5 JAIRO MESA COCK 05-12-2012 20:07 Quien quiera analizar éste caso, tenga en cuenta que es una nueva enseñanza del Servicio de Dermatología de la Universidad de Antioquia... hace unos meses nos enviaron un caso muy bello de unas consecuencisas cutáneas causadas por una pancreatitis... pero sin ningún dato orientador hacia ella, en la historia... por eso, puede ser otra gran sorpresa y vamos a aprender de ella... en concreto me gustan estos casos detectivescos.. . Jairo Citar #4 JAIRO MESA COCK 05-12-2012 19:28 también puede entar en consideración, la dermatomiositis... jairo Citar #3 JULIA INES MESA VILLEGAS 05-12-2012 18:07 Se refiere a las articulaciones: MCF= metacarpofaláng icas IFP = Interfalángicas proximales. Citar #2 JAIRO MESA COCK 05-12-2012 15:07 que significan las siglas MCF e IFP? jairo Citar #1 JAIRO MESA COCK 05-12-2012 15:05 Cuando ví las lesiones de los pabellones, pensé en perniosis, pero la historia no vá por allí… me gusta este caso, porque no está de bola a bola… entonces… pensé en una vasculitis parecida a la livedo reticularis... para confirmarla o negarla, le haría biopsia a las lesiones de brazo…. las del pabellón mostrarían muchos glóbulos rojos que pueden enmascarar… estoy seguro de que hay una vasculitis… la posible causa?... parece ser algo sistémico, consuntivo y con compromiso articular… una colagenosis? LES y Sjögren son candidatos … crioglobulinemi a, criofibrinogene mia, sindrome antifosfolípido s, macroglobulinem ia de waldeströn u otra malignidad… aunque la historia no habla de nódulos, tendría en cuenta la peri o poliarteritis nodosa ... son otras posibilidades… pediría, además de la biopsia del brazo, rx de tórax, hemograma con recuento de plaquetas, anticuerpos antinucleares, criofibrinas, fibrinógeno, electroforesis de proteinas y los ANCA… a esperar… jairo