ANCA-Associated Glomerulonephritis Due to Levamisole-Adulterated Cocaine Use

Introduction: ANCA associated glomerulonephritis/vasculitis is a severe autoimmune disorder characterized by inflammation in kidneys and small blood vessels. A significant rise in cases has been linked to use of cocaine adultered with levamisole. We present a case that highlights the renal complications associated with such drug use, emphasizing the need for diagnostic and therapeutic strategies. Case Description: A 40-year-old female presented to the emergency department with midepigastric abdominal discomfort radiating to the right upper quadrant, accompanied by nausea and vomiting, on examination she was found pale and with lower extremity edema. On initial evaluation she was found with cholecystitis and labs showing acute kidney injury, anemia and hyperkalemia. The patient’s medical history was significant for iron deficiency anemia and chronic kidney disease (CKD), with a social history of cocaine use,last used three weeks prior. She underwent cholecystectomy, but as her kidney function deteriorated she was started on hemodialysis. A kidney biopsy was performed. Biopsy results demonstrated crescentic glomerulonephritis, pauci-immune type, with advanced chronic sclerosis features. Serology testing was positive for atypical perinuclear ANCA (P-ANCA) with a titer of 1:160. Consequently, the patient was diagnosed with ANCA-associated glomerulonephritis secondary to cocaine use adulterated with levamisole. Discussion: This case highlights the severe renal complications associated with ANCA-associated glomerulonephritis induced by levamisole-adulterated cocaine. This condition is characterized by the formation of ANCAs targeting myeloperoxidase (MPO) and proteinase 3 (PR3), leading to neutrophil activation, NET release, immune complex formation, and direct nephrotoxic effects. Therapeutic management involves induction therapy with glucocorticoids and cyclophosphamide, and long-term maintenance with rituximab or azathioprine to prevent relapse. Despite treatment, ongoing cocaine use complicates management, with some progressing to end-stage renal disease. Counseling on cocaine cessation is essential to avoid recurrence. The increasing prevalence of levamisole-adulterated cocaine presents diagnostic and therapeutic challenges, necessitating a high index of suspicion for ANCA-associated glomerulonephritis in patients with unexplained renal dysfunction and cocaine use.