Pulmonary-Renal Syndrome from Cocaine-Induced ANCA-Associated Vasculitis: A Case Report

Introduction: Approximately 71% of cocaine samples obtained in the United States are adulterated with Levamisole, an anthelminthic drug with immunomodulatory properties that is used to increase the weight and potency of cocaine. Case reports have linked Levamisole-contaminated cocaine with an ANCA-associated vasculitis (AAV). We present a case of AAV manifesting as a pulmonary-renal syndrome with undetectable complement levels following cocaine use. Case Description: A 75-year-old African American man with a past medical history of type 2 diabetes mellitus, hypertension, COPD, heart failure with reduced ejection fraction, paroxysmal atrial fibrillation, chronic Hepatitis C infection, and MGUS presented with chest pain and leg edema without a rash. He reported nasal inhalation of cocaine 3 days prior to admission. Serum creatinine on presentation was 3.22 mg/dL and continued to worsen. Urine microscopy showed muddy brown casts. His hospital course was complicated by new-onset hemoptysis which progressed to diffuse alveolar hemorrhage (DAH) requiring intubation and critical care support. Serum complement levels were undetectable. Hepatitis C titers showed 541,000 copies, however, rheumatoid factor assay and test for cryoglobulinemia remained negative. ANCA titers showed positivity for MPO antibodies. Kidney biopsy specimen showed focal necrotizing and crescentic glomerulonephritis (50% active lesions) in the absence of immune complex deposits compatible with AAV. He received immunosuppression with steroids and cyclophosphamide, underwent 7 rounds of plasmapheresis, and was initiated on renal replacement therapy. He had complete resolution of DAH and was extubated while on pheresis. He remained dialysis dependent at 2 month follow up at the time of discharge to subacute rehabilitation. Discussion: Cocaine-induced AAV can present with a variety of symptoms and signs due to involvement of multiple organ systems including life-threatening pulmonary-renal syndrome. While role of pheresis is limited in levamisole-induced AAV, resolution of DAH was noted in our patient.