PMC4849970_01
Skin lesions: A, Retiform purpura with a small area of
necrosis in the right earlobe (pre-treatment). B, Residual skin
lesions in the right earlobe after 3 weeks of immunosuppressive treatment.
C, Purpuric violaceous lesions with surrounding erythema in
the lower limb. Skin biopsy: D, Immunohistochemistry with
anti-CD61 antibody showing positive staining for thrombi inside the vascular
lumen, with surrounding inflammation of the vessel wall (magnification 100x).
E, Small vessel vasculitis with neutrophilic inflammation and
leukocytoclasia (H&E, magnification 100x).
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The auricula was edematous and purpuric, with focal necrosis, as shown in Figure 1. Skin biopsy revealed a neutrophilic vasculitis in small vessels with eosinophils, leukocytoclasia, and fibrinoid necrosis (Figure 1).
Kidney biopsy: A, Chronic tubulointerstitial inflammatory
infiltrate composed mainly by lymphomononuclear cells (H&E, 100x
magnification). B, The glomerulus exhibits a cellular crescent
and mesangial hypercellularity (H&E, 400x magnification). C,
Multifocal rupture of the glomerular basement membrane, with a cellular crescent
in the Bowman's space (methenamine silver, 400x magnification).
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Podocyte hypertrophy, focal mesangiolysis, a diffuse and chronic inflammatory infiltrate in the tubulointerstitium, and interstitial fibrosis and tubular atrophy in 10% of total cortical area were also observed (Figure 2).
Evolution of renal function over 3 months of follow-up and its relation to
urine toxicology for cocaine and levamisole, and to therapeutic interventions
(methylprednisolone and cyclophosphamide intravenous (iv)
pulses).
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One month after hospital discharge, the patient reported abstinence from cocaine, which was confirmed by negative urine samples for cocaine or levamisole, and exhibited progressive improvement of renal function (Figure 3).