Dermatologic Therapy, Vol. 26, 2013, 476–480 Printed in the United States · All rights reserved

© 2013 Wiley Periodicals, Inc.

DERMATOLOGIC THERAPY ISSN 1396-0296

THERAPEUTIC HOTLINE Levamisole-induced myopathy and leukocytoclastic vasculitis: a case report and literature review Meng-Hsuan Tsai*, Jen-Hung Yang†‡, Sheng-Ling Kung§ & Yu-Ping Hsiao¶** *Department of Medical Education and Family Medicine, National Taiwan University Hospital, Taipei, †School of Medicine, Tzu Chi University, ‡Department of Dermatology, Buddhist Tzu Chi General Hospital, Hualien, §Department of Neurology, ¶Department of Dermatology, Chung Shan Medical University Hospital, and **Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan

ABSTRACT: Levamisole, an immunomodulator and anthelmintic medication, has been used in dermatology for years. Even though the adverse effects are usually mild and reversible, attention should be paid toward severe events such as vasculitis and neutropenia. To the best of our knowledge, this is the first case report on a patient presenting with myopathy caused by levamisole. Here, we report a 34-yearold woman with recalcitrant warts who received levamisole 100 mg daily for 5 days. Subsequently, bilateral lower limb weakness accompanied by multiple painful and non-blanchable purpura was noted. Levamisole-induced myopathy and leukocytoclastic vasculitis were diagnosed by skin histopathology, direct immunofluorescence, and electromyography. After discontinuing levamisole and giving a short course of systemic steroid, these symptoms demonstrated a resolving trend. KEYWORDS: leukocytoclastic vasculitis, levamisole, myopathy

Introduction

the first case report of levamisole-induced myopathy in the English literature review.

Levamisole is a US Food and Drug Administrationapproved drug that has been used as an immunomodulator, anthelmintic, and a chemotherapy adjuvant (1). Herein, we describe a patient with levamisole-induced myopathy and leukocytoclastic vasculitis. To the best of our knowledge, this is

Case report

Address correspondence and reprint requests to: Yu-Ping Hsiao, MD, Attending Physician, Department of Dermatology, Chung Shan Medical University Hospital, No.110, Sec.1, Chien-Kuo N.Rd. Taichung City 402, Taiwan, or email: [email protected].

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A 34-year-old woman was admitted to the hospital due to multiple painful purpuras and lower limb weakness for 3 days. She is not a drug abuser and has been quite well before until 3 months ago, when she developed several painful nodules over the right sole. She visited a local practitioner’s clinic, where a diagnosis of recalcitrant warts was made, with a prescription for levamisole (100 mg daily) orally for 5 days. Subsequently, she noted

Levamisole-induced myopathy and vasculitis

lower limb weakness that gradually worsened, leading to difficulty walking. In addition, she developed progressive multiple tender erythematous papules distributed along the buttocks and the lower limbs (FIG. 1A). On examination, the temperature was 37.8°C, the blood pressure 130/80 mmHg, the pulse 88 beats per minute, and the respiratory rate 18 breaths per minute. Neurological examination demonstrated that the strength in both arms was 5 out of 5, whereas the strength in the quadriceps, hamstrings, tibialis anterior, and extensor hallucis longus muscles was 3 out of 5 on the left and 4 out of 5 on the right. The deep tendon reflex was normal. She did not report headache, neck stiffness, respiratory distress, hemoptysis, chest pain, abdominal pain, hematuria, bloody stool, or other discomforts. There was no heliotrope erythema or Gottron’s papules. The laboratory data revealed elevated levels of creatine kinase: 1026 IU/L (normal range: 32–180 IU/L), creatinine kinaseMB form: 19 IU/L (normal range:

Levamisole-induced myopathy and leukocytoclastic vasculitis: a case report and literature review.

Levamisole, an immunomodulator and anthelmintic medication, has been used in dermatology for years. Even though the adverse effects are usually mild a...
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