CASE REPORT PATHOLOGY AND BIOLOGY Erwan Le Garff, 1 M.D.; Gilles Tournel, 1,2 M.D., Ph.D.; Coralie Becquart, 3 M.D.; Olivier Cottencin, 4 M.D., Ph.D.; Nicolas Dupin, 5 M.D., Ph.D.; Emmanuel Delaporte, 3 M.D., Ph.D.; and Val  ery Hedouin, 1 M.D., Ph.D. Extensive Necrotic Purpura in Levamisole- Adulterated Cocaine Abuse – A Case Report ABSTRACT: Levamisole, which is used as an adulterated compound of cocaine, is currently being seen year after year in cocaine intoxica- tion. For a few cases in the last decade, necrotic purpura and neutropenia after levamisole/cocaine intoxication have been described in the med- ical community. Herein, we present an original case of levamisole intoxication of a 40-year-old woman who smoked heroin and cocaine few during a month. She rapidly presented an extensive necrotic purpura of the nose, cheeks and extremities (lower and upper), and immunologic reactions (positive anti-MPO and anti-HNE). Levamisole was detected on hairs with ultra-high performance liquid chromatography and tandem mass spectrometry. The case reports also a probable cocaine supplier deceit, which bring pure drug for hospital investigation after the intoxica- tion of his client. The intoxicated woman had survived with several skin and chronic pain complications. That case recalls the knowledge about levamisole with a short review of the forensic literature. KEYWORDS: forensic science, levamisole, cocaine, necrotic purpura, legal medicine, toxicology Cocaine consumption is increasing around the world, and there are approximately 2 million users (1,2). Levamisole, an anti- helminthic that was first produced in 1966, has been commonly found in adulterated cocaine for years (3). Levamisole is associated with a clinical manifestation of skin purpura and laboratory obser- vations such as neutropenia and immunologic reactions. Herein, we present a recent case of levamisole intoxication and detail the clinical presentation, biological parameters, and toxicology investi- gation highlighted by the medical and forensic literature. Case Report Clinical Presentation A 40-year-old woman presented with painful skin lesions on her right upper extremity without medical examination. Accord- ing to the patient, the lesions healed spontaneously in 2 weeks. A recurrence of the lesions was observed 1 month later in the same location and without medical consultation. A third episode was again observed 2 months after the first episode with painful skin lesions of the nose, cheeks, ears, back of the hands, and lower extremities. Five days after hospitalization, the patient admitted to using heroin and cocaine immediately before the skin lesions appeared in both episodes. For the recent episode, she reported only smoking cocaine and heroin that was supplied to her by her regular supplier. The patient had a past medical history of heroin (intravenous) and cocaine (intravenous and sniff) abuse, hepatitis C virus, and septic shock with staphylo- coccus aureus and streptococcus infections in 2009. No previous documented history of any type of autoimmune disorder was reported prior to the described episode. Neither documented allergy nor allergy manifestation was reported too. In the emer- gency department and during hospitalization, she presented with necrotic evolution of the skin lesions with enlargement (Figs 1 and 2). Skin grafts on the lower extremities and wound healing of the rest of the skin lesion were performed. The addiction medicine unit of the hospital proposed treatment for her cocaine and heroin addiction, but she declined this medical follow-up and did not attend all of her dermatologic consultations. Laboratory Investigations The laboratory investigations did not show signs of infection in the blood sample cultures or in the cerebrospinal fluid. The labora- tory analyses showed acute kidney failure (serum creatinine 15 mg/L) without additional anomalies such as anemia (12.2 g/dL of hemoglobin; 227,000/mm 3 blood platelets; 12,000/mm 3 leuko- cytes; and 8300/mm 3 neutrophils) or thrombocytopenia (increased activated partial thromboplastin time [APTT] measured at 57 sec and normal prothrombin time [PT]). Antibodies anti-beta2 glyco- protein 1 or anticardiolipin were negative. Lupus anticoagulant screening was positive, with a Rosner Index of 40.7. Antinuclear antibodies (ANA) were weakly positive with a titer of 1:80 1 Service de M edecine L egale, CHU Lille, University Lille, UTML 7367, F-59000 Lille, France. 2 Service de toxicologie, CHU Lille, University Lille, F-59000 Lille, France. 3 Service de dermatologie, CHU Lille, University Lille, F-59000 Lille, France. 4 ScaLab CNRS UMR 9193, Service d’addictologie, CHU Lille, University Lille, F-59000 Lille, France. 5 Service de dermatologie, CHU Cochin, Rue du Faubourg St Jacques, 75014 Paris, France. Received 2 Oct. 2015; and in revised form 26 Jan. 2016; accepted 30 Jan. 2016. 1 © 2016 American Academy of Forensic Sciences J Forensic Sci, 2016 doi: 10.1111/1556-4029.13176 Available online at: onlinelibrary.wiley.com