Levamisole-induced Necrosis Syndrome: Presentation and Management.

Levamisole is an antihelminthic drug with immunomodulatory properties. Recent estimates suggest the majority of the cocaine in the United States is adulterated with levamisole. Levamisole-induced necrosis syndrome (LINES) is characterized by vasculitis, neutropenia, and purpura that progresses to skin necrosis. Diagnosis relies on physical examination findings and history of previous cocaine use. The purpose of this case series is to describe the pathophysiology, diagnosis, and management of LINES. The authors' institutional database was reviewed from 2008 to 2015, and they found 3 patients with LINES. Subsequent management and outcomes data are discussed. Patients had a variety of outcomes ranging from local wound care to necrosis and amputation of phalanges. Patients with LINES can have a wide variety of outcomes; thus, this syndrome must be aggressively managed. Psychotherapy should also be utilized to help patients with further cocaine use. Levamisole-induced necrosis syndrome incidence is expected to increase, and all providers should be aware of this patient population.