Exposure to levamisole, a prevalent adulterant of illicit cocaine in North America, can induce a distinctive clinical syndrome of retiform purpura and cutaneous necrosis affecting the extremities, ears, and skin overlying the zygomatic arch.

The syndrome has been linked to neutropenia, agranulocytosis, and pauci-immune glomerulonephritis.

It is associated with the lupus anticoagulant, IgM antibodies to cardiolipin, and very high titers of p-ANCAs (due to autoantibodies to elastase, lactoferrin, cathepsin-G, and other neutrophil components rather than to myeloperoxidase alone).

Biopsies reveal widespread thrombosis of small cutaneous vessels with varying degrees of vasculitis.

There is no consensus on treatment of levamisole-induced purpura, but early lesions can resolve with abstinence.

There may be long-term sequelae of levamisole exposure, such as deforming cutaneous lesions, arthralgias, and arthritis.

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