Scrotal gangrene after smoking crack

September 28, 2010, 11:24 am

★★☆☆☆

Cocaine-Related Vasculitis Causing Scrotal Gangrene. Chen SC et al. Ann Pharmacother 2009;43:375-378

Abstract

This 2009 case report from Taiwan deserves attention and re-examination. The authors describe the case of a 22-year-old daily crack cocaine smoker who developed swelling and ulcerations of his scrotum.  He was initial treated with IV antibiotics for presumed orchitis, but further testing excluded infectious causes, revealing instead evidence of vasculitis.  The authors performed a limited literature review of cocaine-associated vasculitis, and conclude that in their case the development of vasculitis was possibly associated with cocaine use. Previously reported cases of cocaine-associated vasculitis have mimicked Wegener’s granulomatosis; however in this case, typical lab features of this disease were absent.

In light developments that occurred since publication of this report, I think that levamisole should now be considered as a cause of vasculitis in this case. It is now clear that levamisole is an adulterant in a large percentage of cocaine shipments that enter the United Sates.  Earlier this year, a case of levamisole-induced necrotizing vasculitis of the ears was published. Given that the authors of this current case report were not able to identify a convincing cause of the patient’s scrotal vasculitis, it is not unreasonable to think that levamisole very likely could have been involved.  In any case, authors future case reports about effects of “cocaine” or any other illicit drugs should make rigorous efforts and analyze a sample of the drug involved.  That will be the only was to get good data, and truly “crack” the case.

This case report is especially worth seeking out for the remarkable full color photos of the necrotic lesions (ouch!) and the pathology slides.

– Mark Mycyk MD

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