Granulomatosis with polyangiitis or its mimic? A case report.

Differentiation between granulomatosis with polyangiitis (GPA) limited to the upper airways and cocaine-induced midline destructive lesion (CIMDL) may be particularly difficult because of their common histopathologic features and antineutrophil cytoplasmic antibody (ANCA) profiles. We herein present a case involving a young woman with an initial diagnosis of GPA based on upper and lower airway manifestations and constitutional symptoms, histopathologic evidence of granulomas, a positive cytoplasmic ANCA indirect immunofluorescent test result, and proteinase 3 positivity by enzyme-linked immunosorbent assay (ELISA). CIMDL was confirmed based on the appearance of a hard palate perforation, positivity for methylecgonine on urine toxicology, a positive perinuclear ANCA indirect immunofluorescent test result, and subsequent human neutrophil elastase (HNE) ANCA positivity by ELISA. Finally, based on the coexistence of CIMDL, constitutional symptoms, and lower airway manifestations, the diagnosis was modified to cocaine-induced GPA mimic. Urine toxicology for cocaine and HNE ELISA are indicated in young patients with GPA who develop limited airway disease to check for the presence of CIMDL and cocaine-/levamisole-induced ANCA-associated vasculitis. Continued abstinence from cocaine is the first-choice therapy for both CIMDL and cocaine-induced GPA mimic.

Cocaine use in trauma: the vices-paradox revisited.

BACKGROUND: The "vices-paradox" describes the paradoxical association between illicit substance use and decreased mortality risk in trauma patients. Cocaine's vasoconstrictive effects may decrease hemorrhage but also increase the risk of thromboembolic complications. To clarify the effects of cocaine use on trauma patients, we compared the risk of mortality and thromboembolic complications in patients screening positive for cocaine with those screening negative. METHODS: We searched the Trauma Quality Improvement Program database to identify patients 18 years and over who had presented with a drug and alcohol screen on admission between 2017 and 2019. After excluding all patients who had tested positive for alcohol and substances other than cocaine, we then compared the clinical outcomes of patients who were positive and negative for cocaine use. RESULTS: Of the 312,553 patients identified, 11,942 (3.82%) had tested positive for cocaine. Cocaine users were significantly more likely to present with stab (8.0% vs 3.1%) or gunshot wounds (8.0% vs 3.0%) but had lower rates of mortality (3.6% vs 4.7%), myocardial infarction (0.1% vs 0.2%,) and cerebrovascular accident (0.3% vs 0.4%,). After controlling for covariates, the risk of death, myocardial infarction, and cerebrovascular accident did not significantly differ between cocaine and non-cocaine users. CONCLUSION: Trauma patients positive for cocaine have similar risks of death and thromboembolic complications and so have a similar prognosis to patients negative for all drugs or alcohol, indicating that the "vices-paradox" does not apply to cocaine use. However, these patients more commonly present after penetrating trauma, suggesting cocaine use in hazardous environments.

Cocaine Use May Moderate the Associations of HIV and Female Sex with Neurocognitive Impairment in a Predominantly African American Population Disproportionately Impacted by HIV and Substance Use.

HIV-associated neurocognitive disorders (HAND) remain a major challenge for people with HIV in the antiretroviral therapy era. Cocaine use may trigger/exacerbate HAND among African American (AA) adults, especially women. Between 2018 and 2019, 922 adults, predominantly AAs, with/without HIV and with/without cocaine use in Baltimore, Maryland, were enrolled in a study investigating the association of HIV and cocaine use with neurocognitive impairment (NCI). Neurocognitive performance was assessed with the NIH Toolbox Cognition Battery (NIHTB-CB). NCI was considered to be present if the fully adjusted standard score for at least two cognitive domains was 1.0 standard deviation below the mean. Although the overall analysis showed HIV and female sex were associated with NCI, the associations were dependent on cocaine use. Neither HIV [adj prevalence ratio (PR): 1.12, confidence interval (95% CI): 0.77-1.64] nor female sex (adj PR: 1.07, 95% CI: 0.71-1.61) was associated with NCI among cocaine nonusers, while both HIV (adj PR: 1.39, 95% CI: 1.06-1.81) and female sex (adj PR: 1.53, 95% CI: 1.18-1.98) were associated with NCI in cocaine users. HIV was associated with two NIHTB-CB measures overall. In addition, HIV was associated with a lower dimensional change card sort score (an executive function measure) in cocaine users and not in nonusers. Cognitive performance was poorer in female than in male cocaine users. The adverse effect of HIV on cognitive performance predominantly affected cocaine users. However, cocaine use may moderate the impact of HIV and female sex on cognitive performance, highlighting the importance of reducing cocaine use in NCI prevention among the AA population.

A Case of Chronic Intranasal Cocaine Abuse Masquerading and Exacerbating Underlying Orbital IgG4-Related Disease.

Chronic cocaine use may lead to widespread intranasal inflammation and necrosis. Cases of cocaine use affecting the orbit have been reported in the literature with a clinical spectrum ranging from inflammation-induced p-anti-cytoplasmic neutrophil autoantibodies positive vasculitis to severe midline destructive lesions resulting in orbital apex syndrome. Here, we present a case of chronic intranasal cocaine abuse with midline destruction that initially obscured diagnosis of, and is hypothesized to have exacerbated, underlying IgG4-Related Disease (IgG4-RD) of the orbit over a 2-year period.

Lesiones dentales por el uso de cocaína / Dental lesions due to the use of cocaine

El consumo, abuso y adicción de sustancias ilícitas, como por ejemplo la cocaína, es uno de los problemas de salud pública más preocupante en nuestro país, con diferentes índices en el conurbano. El uso de cocaína en estos medios produce daños en distintos órganos, entre los cuales podemos mencionar, corazón, cerebro, riñón y también en tejidos duros como los dientes, daños y lesiones a las que haremos referencia en este artículo. El caso presentado en este trabajo es el de un paciente de 21 años, que ingresa a la guardia por traumatismo de cráneo moderado producido por una colisión moto-autobús. Sus familiares no refieren antecedentes de enfermedades previas. Se interna en la Unidad de terapia intensiva; y llama la atención, al realizar el examen físico, las lesiones observadas en los dientes incisivos y premolares de la arcada dentaria superior.

The consumption, abuse, and addiction of illicit substances, such as cocaine, is one of the most worrying public health problems in our country, with different indices in the conurbano. The use of cocaine in these media produces damage to different organs, among which we can mention, heart, brain, kidney and also in hard tissues such as teeth, damage and injuries to which we will refer to this article. The case presented in this work is that of a 21-year-old patient, who enters the guard for moderate skull trauma produced by a motorcycle-autobus collision. His relatives do not refer to a history of previous diseases. It goes into the Intensive Therapy Unit; And it attracts attention, when performing the physical exam, the lesions observed in the incisive and premolars of the upper dental arcade

Cocaine use associated gut permeability and microbial translocation in people living with HIV in the Miami Adult Study on HIV (MASH) cohort.

OBJECTIVE: Determine if cocaine use impacts gut permeability, promotes microbial translocation and immune activation in people living with HIV (PLWH) using effective antiretroviral therapy (ART). METHODS: Cross-sectional analysis of 100 PLWH (ART ≥6 months, HIV-RNA <200 copies/mL) from the Miami Adult Studies on HIV (MASH) cohort. Cocaine use was assessed by self-report, urine screen, and blood benzoylecgonine (BE). Blood samples were collected to assess gut permeability (intestinal fatty acid-binding protein, I-FABP), microbial translocation (lipopolysaccharide, LPS), immune activation (sCD14, sCD27, and sCD163) and markers of inflammation (hs-CRP, TNF-α and IL-6). Multiple linear regression models were used to analyze the relationships of cocaine use. RESULTS: A total of 37 cocaine users and 63 cocaine non-users were evaluated. Cocaine users had higher levels of I-FABP (7.92±0.35 vs. 7.69±0.56 pg/mL, P = 0.029) and LPS (0.76±0.24 vs. 0.54±0.27 EU/mL, P<0.001) than cocaine non-users. Cocaine use was also associated with the levels of LPS (P<0.001), I-FABP (P = 0.033), and sCD163 (P = 0.010) after adjusting for covariates. Cocaine users had 5.15 times higher odds to exhibit higher LPS levels than non-users (OR: 5.15 95% CI: 1.89-13.9; P<0.001). Blood levels of BE were directly correlated with LPS (rho = 0.276, P = 0.028), sCD14 (rho = 0.274, P = 0.031), and sCD163 (rho = 0.250, P = 0.049). CONCLUSIONS: Cocaine use was associated with markers of gut permeability, microbial translocation, and immune activation in virally suppressed PLWH. Mitigation of cocaine use may prevent further gastrointestinal damage and immune activation in PLWH.

Cannabis and cocaine use, drinking outcomes, and quality of life in general hospital inpatients with alcohol use disorder.

Background: While associations between cannabis and cocaine use, and heavy drinking and quality of life (QOL), are well-established in the general population, it is unclear whether they are present in hospital inpatients with alcohol use disorder (AUD). The aim of the study was to assess associations between cannabis and cocaine use and two outcomes [heavy drinking days (HDDs) and QOL] among hospital inpatients with AUD. Methods: Hospitalized patients with AUD and at least one past-month HDD participated in this cross-sectional study. Cannabis and cocaine use were assessed using the Alcohol, Smoking, and Substance Involvement Screening Test. HDDs were assessed using the Timeline Followback. QOL was assessed by the WHOQOL-BREF instrument. Multivariable regression models assessed associations. Results: Of 248 participants, 225 (91%) had severe AUD. There were no statistically significant associations between: recent cannabis use and HDDs [Incidence Rate Ratio (IRR) = 0.95; 95% Confidence Interval (95% CI): 0.80, 1.14], cocaine use and HDDs [IRR = 0.88; 95% CI: 0.66, 1.18], or both cannabis and cocaine use and HDDs [IRR = 0.87; 95%CI: 0.70, 1.09], as compared to use of neither cannabis nor cocaine. Use of cannabis, cocaine, and both, were not associated with QOL [(odds ratio (OR) = 0.98; 95% CI:0.55, 1.74), (OR = 0.76; 95% CI:0.30, 1.93), (OR = 1.00; 95%CI: 0.49, 2.03), respectively]. Conclusions: Among hospital inpatients with AUD, there were no significant associations between cannabis and cocaine use, heavy drinking, or QOL. Our findings raise questions regarding how drug use affects AUD and whether similar results would be found among those with milder AUD and in prospective studies.

Crack cocaine abuse as an undescribed cause of gastric outlet obstruction.

A 32-year-old male with crack-cocaine abuse for 10 years, 300 g/day. He started with epigastric abdominal pain, intensity 10/10, he went to another hospital where a perforated peptic ulcer was suspected and a laparotomy was performed, with no findings. Subsequently, he started with vomiting and weight loss, on admission, a gastric outlet obstruction (GOO) was suspected and CT scan showed a concentric duodenal growth. An upper endoscopy identified a duodenal bulb stenosis with a Forrest-III ulcer. Roux-en-Y gastrojejunal anastomosis was performed, identifying duodenal thickening, without malignancy.

Smoke Gets in the Eye: A systematic review of case reports of ocular complications of crack cocaine use.

ISSUES: Use of crack cocaine and associated medical complications persists globally. Some reports in medical literature describe a sight-threatening condition commonly referred to as 'crack eye' or 'crack eye syndrome'. The purpose of this review is to describe what is known about crack eye from case reports in peer-reviewed literature. APPROACH: A structured search was completed in MEDLINE, TOXLINE, EMBASE, PsychInfo, Scopus and Biomed Central, to collect case reports and case series on corneal complications attributed to crack cocaine smoking. KEY FINDINGS: Of 111 articles screened, 11 contained case reports or series. Thirty individual cases of 'crack eye' were reported. The majority (63%) of cases had bilateral involvement; 83% of all cases with microbial culture results had corneal infections. Aggressive treatment caused an improvement in 95% of all cases and 23% of all cases were lost to follow up. Of those who received treatment for corneal complications associated with crack cocaine, 22% remained with significant visual impairment (hand motions only) in the affected eye. IMPLICATIONS: Clinicians should consider crack cocaine involvement in patients presenting with corneal disease without known predisposing factors, and elicit comprehensive drug histories to prevent a reduction in visual acuity. CONCLUSION: Corneal complications of crack cocaine smoking are caused by a number of synergistic factors, including direct toxicity of crack cocaine vapours to surface cells, impairment of neurogenic support to corneal epithelial integrity, desiccation of the eye surface due to diminished blinking reflex, low level chemical burns and mechanical denudement of surface cells through eye rubbing.

Neutrophilic dermatosis of the dorsal hands related to cocaine abuse

Abstract Neutrophilic dermatoses encompass a wide spectrum of diseases characterized by a dense infiltration mainly composed of neutrophils. Neutrophilic dermatosis of the dorsal hands is currently considered a localized variant of Sweet syndrome. Cocaine abuse has been related to a wide range of mucocutaneous manifestations, including neutrophilic dermatoses such as pyoderma gangrenosum. The authors of this study present a patient with neutrophilic dermatosis of the dorsal hands, in which cocaine abuse was identified as a probable trigger.

Reverse Takotsubo Cardiomyopathy Precipitated by Chronic Cocaine and Cannabis Use.

This case report describes a 31-year-old man with 10 years of cocaine and cannabis dependence who developed reverse Takotsubo cardiomyopathy (rTC), a rare variant of Takotsubo cardiomyopathy. He presented to the Emergency Department (ED) with severe left temporal headache and vomiting which began whilst smoking cannabis and several hours after smoking methamphetamine and using cocaine via insufflation. Computed tomography and angiography of the brain was normal, and the headache resolved with analgesia. Urine drug screen was positive for benzodiazepines, cannabinoids, cocaine, opiates (attributed to morphine administered in ED) and amphetamines. Three hours later he had a seizure and within 10 min developed cardiogenic shock with antero-inferior ST segment depression on electrocardiogram and troponin-T rise to 126 ng/L. Coronary angiography demonstrated normal coronary arteries. Transthoracic echocardiogram demonstrated severely impaired left ventricular (LV) systolic function with ejection fraction 15-20% and hypokinesis sparing the apex. Thyrotoxicosis, nutritional, vasculitic, autoimmune and viral screens were negative. Cardiac magnetic resonance imaging demonstrated severe LV functional impairment with dilated and hypocontractile basal segments, and T2 hyperintensity consistent with myocardial oedema and rTC. He received supportive management. Proposed mechanisms of rTC include catecholamine cardiotoxicity and coronary artery vasospasm. In this case, multiple insults including severe headache, cannabis hyperemesis and cocaine and methamphetamine-induced serotonin toxicity culminated in a drug-induced seizure which led to catecholamine cardiotoxicity resulting in rTC. Clinicians should be cognizant of stress cardiomyopathy as a differential diagnosis in patients with substance use disorders.

Survival Probabilities and Predictors of Major Depressive Episode Incidence Among Individuals With Various Types of Substance Use Disorders.

Objective: This study aimed to estimate the survival probabilities related to the occurrence of major depressive episodes (MDEs) after the onset of substance use disorders (SUDs) using data from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III.Methods: The Alcohol Use Disorder and Associated Disabilities Interview Schedule-5 was used to diagnose SUD, and psychiatric diagnoses were based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Individuals with incidents of various SUDs with no prior history of MDEs (n = 5,987 with alcohol use disorder [AUD], 1,353 with cannabis use disorder [CUD], 351 with opioid use disorder [OUD], 827 with stimulant use disorder [STUD], and 5,363 with nicotine use disorder [NUD]) were included. The survival probabilities of these groups were compared to those of a control group without an SUD (n = 20,034). Outcome measures included the number of years from the age at SUD onset until MDE occurrence or the time of the interview.Results: The probabilities of experiencing MDEs after 1 year were 3.56%, 4.80%, 7.78%, 8.46%, and 5.31% for AUD, CUD, OUD, STUD, and NUD, respectively. The groups differed statistically significantly from each other and from the control group (P < .0001). Individuals with AUD and STUD, respectively, had a lower and higher probability of having an MDE compared to those with other SUDs. Young age, family history of depression, anxiety disorder presence, and failure to achieve full remission consistently predicted an MDE for all substances.Conclusions: The findings highlight that users of all studied substances have an increased probability of having an MDE over the lifespan.

Cocaine Use and White Matter Hyperintensities in Homeless and Unstably Housed Women.

OBJECTIVES: Cocaine use has been linked to stroke in several studies. However, few studies have considered the influence of cocaine use on stroke mechanisms such as small vessel disease (SVD). We conducted a study to assess associations between the toxicology-confirmed use of multiple drugs, including cocaine, and a marker of SVD, white matter hyperintensities (WMH). MATERIALS AND METHODS: We conducted a nested case-control study (n = 30) within a larger cohort study (N = 245) of homeless and unstably housed women recruited from San Francisco community venues. Participants completed six monthly study visits consisting of an interview, blood draw, vital sign assessment and baseline brain MRI. We examined associations between toxicology-confirmed use of multiple substances, including cocaine, methamphetamine, heroin, alcohol and tobacco, and WMH identified on MRI. RESULTS: Mean study participant age was 53 years, 70% of participants were ethnic minority women and 86% had a history of cocaine use. Brain MRIs indicated the presence of WMH (i.e., Fazekas score>0) in 54% (18/30) of imaged participants. The odds of WMH were significantly higher in women who were toxicology-positive for cocaine (Odd Ratio=7.58, p=0.01), but not in women who were toxicology-positive for other drugs or had several other cerebrovascular risk factors. CONCLUSIONS: Over half of homeless and unstably housed women showed evidence of WMH. Cocaine use is highly prevalent and a significant correlate of WMH in this population, while several traditional CVD risk factors are not. Including cocaine use in cerebrovascular risk calculators may improve stroke risk prediction in high-risk populations and warrants further investigation.

Pyoderma gangrenosum associated to the use of cocaine/levamisole. Series of three cases and literature review

Abstract Pyoderma gangrenosum associated to the use of cocaine/levamisole is a rare condition associated to their consumption. Cocaine use is frequent in Colombia, and the substance is contaminated with levamisole, an anthelmintic that increases the psychotropic effects and enhances its side effects. We present three clinical cases of patients with ulcerated lesions, in which the diagnosis was pyoderma gangrenosum secondary to the use of cocaine contaminated with levamisole. This called the attention of the health staff to investigate the abuse of substances in gangrenous pyoderma and also evidence that the interruption of consumption was the basis of management.

Rare cause of acute abdomen-cocaine-induced small intestinal perforation with coexisting lower gastrointestinal bleed: an unusual presentation.

Cocaine, an alkaloid, is an addictive drug and its abuse as a recreational drug is on the increasing side with its associated complications. Gastrointestinal complications, after cocaine abuse, are less known and need to be addressed since the abuse is on the rise and the existing evidence is scarce. We report a case of a 22-year-old male patient who presented with abdominal pain following a cocaine injection. On examination, signs of peritonitis were noted and laparotomy revealed a 2×1 cm perforation in the distal ileum. The unhealthy intestinal segment was resected and taken out as a double-barrel ileostomy. The patient had an episode of severe lower gastrointestinal bleeding on postoperative day 6. CT and colonoscopy revealed signs of ischaemic bowel and tissue biopsy showed oedematous, inflamed and haemorrhagic bowel mucosa. The patient was managed conservatively and is doing well under follow-up in a de-addiction centre.

Pyoderma gangrenosum associated with levamisole-adulterated cocaine in a c-ANCA positive patient.

Pyoderma gangrenosum (PG) is an inflammatory, ulcerative condition that is characterized by painful ulcers that commonly present on the lower extremities. Up to half of PG cases are associated with underlying systemic disease, including inflammatory bowel disease, various autoimmune conditions, and malignancy. Another well-known association is the manifestation of PG with recreational cocaine use, especially cocaine contaminated with the adulterant agent levamisole. Once utilized for its immunomodulatory capabilities, levamisole was withdrawn from the market in 2002. It has since been repurposed to potentiate the amphetamine-like effects and duration of cocaine and has reduced preparation cost. We present a 52-year-old woman with chronic maxillary sinusitis and cocaine use disorder presenting with a two-week history of painful ulcers on bilateral lower extremities, each with a purulent base and undermined, violaceous borders. Urine toxicology was positive for cocaine and serologic studies were positive for cytoplasmic antineutrophil cytoplasmic antibodies (c-ANCA) and lupus anticoagulant. Underlying conditions, especially that of granulomatosis with polyangiitis, were considered and ultimately ruled out. The patient's lesions exhibited a marked response with a short course of oral corticosteroids, typical of PG associated with levamisole. This case highlights the crucial role that drug abstinence plays in the prevention of recurrence.

Cocaine-induced mesenteric ischaemia requiring small bowel resection.

Cocaine use causes profound vasoconstriction leading to various systemic complications. Gastrointestinal complications such as mesenteric ischaemia are difficult to recognise and may result in serious consequences if not treated promptly. We report on the case of a 47-year-old man presenting with mesenteric ischaemia on a background of acute on chronic cocaine consumption, where diagnosis was not evident until second presentation. He underwent an emergency laparotomy with small bowel resection and jejunostomy formation and made a good recovery with eventual reversal surgery. The literature on cocaine-induced bowel ischaemia shows significant variability in presentation and outcome. Laboratory investigations are non-specific, and early recognition is vital. Given the increasing recreational use of cocaine in the UK, it is imperative to have a high clinical index of suspicion for mesenteric ischaemia in patients presenting with non-specific abdominal pain, and to ensure a detailed social history covering recreational drug use is not forgotten.

Use of crack cocaine increases tooth loss.

PURPOSE: To evaluate the occurrence of tooth loss among crack cocaine users. METHODS: A cross-sectional study was conducted with 106 crack cocaine users and 106 controls matched for age, gender, and tobacco use. Data were collected on socio-demographic characteristics, drug use, use of dental services, dental caries, periodontal disease, and the outcome (tooth loss). RESULTS: Crack cocaine users had a greater frequency of tooth loss (55.7% vs. 36.8%), severity of dental caries and periodontal disease and less use of dental services than the controls (P< 0.05). After adjustments, tooth loss was 46% more frequent among crack cocaine users (PR= 1.46; 95%, CI: 1.10-1.93) as well as significantly more frequent among non-whites, those older than 24 years of age and those with high dental caries severity. Occurrence of tooth loss was significantly higher among crack cocaine users. These findings can contribute to the planning and implementation of prevention strategies and oral health care for individuals with a chemical dependence. CLINICAL SIGNIFICANCE: The use of crack cocaine had a negative impact on the oral health of its users, leading to tooth loss and a greater severity of dental caries. These findings should be considered when planning prevention strategies to improve oral health in individuals addicted to crack cocaine.

A potential cause of asbestos-related granulomatosis due to adulterant contamination in a drug abuser.

Drug adulterants containing contaminants have been known to cause lung disease by inhalation or intravenous intake. Talcosis due to intravenous talc injection has been widely described in the literature, whereas the hypothesis of granulomatosis due to asbestos related to adulterated cocaine injection has not yet been explored. Herein, a case of pulmonary granulomatosis due to asbestos fibres related to cocaine injection in a young woman is described. Inorganic material in the lung was first individuated by light microscopy and last was identified using the SEM-EDX method. This case is unique since the occupational and passive inhalation of asbestos was excluded with absolute certainty.

Cocaine Consumption and Antineutrophil Cytoplasmic Antibody-associated Glomerulonephritis: A Case Report.

ABSTRACT: Cocaine is often sold in a mixture with levamisole to increase the profit margin and potentiate the euphoric effect. Apart from an overdose, cocaine can induce a wide range of clinical symptoms. We present a case of cocaine/levamisole-induced pauci-immune glomerulonephritis. A 22-year-old patient was sent to the hospital after a laboratory result showed an unexpected acute kidney injury, with an estimated glomerular filtration rate of 34 mL/min/1.73 m2. The medical history included cocaine abuse. Renal biopsy showed a pauci-immune necrotizing glomerulonephritis. Antineutrophil cytoplasmic antibodies were positive with a perinuclear staining pattern and target specificity for leucocyte myeloperoxidase (antimyeloperoxidase). Despite treatment, the kidney function did not show significant improvement. The forensic implication of this case is that even if the toxicological values are not high enough to suggest a lethal intoxication, an idiosyncratic reaction on cocaine and/or levamisole has to be taken into account.