Purpose

Levamisole, a common cocaine adulterant, can trigger severe antineutrophil cytoplasmic antibody (ANCA)-positive vasculitis with rare but devastating ocular manifestations causing irreversible vision loss. We report a case series of four patients who developed rapidly progressive cicatrizing conjunctivitis mimicking mucous membrane pemphigoid (MMP) in the setting of presumed levamisole-adulterated cocaine use.

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Methods

Retrospective case series of four active cocaine users presenting with bilateral cicatrizing conjunctivitis at a tertiary referral center. Cocaine exposure was confirmed by urinary drug screen in all patients; urinary levamisole was tested by mass spectrometry. Informed patient consent was obtained.

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Results

Patients aged 27–50 years (2 male, 2 female), all with a longstanding heavy cocaine use history. All presented with rapidly progressive bilateral symblepharon formation and forniceal shortening. One patient initially presented with recurrent eyelid margin pyogenic granulomas preceding cicatrizing disease. Aggressive lid scarring progressed to near-complete ankyloblepharon in three cases, causing profound visual impairment. Multi-system involvement was present in all cases, including sino-nasal destruction, necrotizing cutaneous vasculitis, and pulmonary disease. PR3-ANCA was positive in three patients. All required immunosuppression escalation with rituximab or azathioprine. Multiple surgical interventions were necessary, including symblepharon lysis and amniotic membrane grafting, with early adhesion recurrence consistently observed with ongoing cocaine use.

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Conclusion

Levamisole-adulterated cocaine can precipitate severe, treatment-refractory cicatrizing conjunctivitis closely mimicking MMP. Early diagnosis is challenging given difficulty to detect levamisole by urinary mass spectrometry due to its short half-life. High clinical suspicion in atypical pemphigoid presentations with concurrent multi-system disease is essential. Prompt immunosuppression and cocaine cessation are critical to prevent irreversible visual morbidity.

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Additional Authors

First name	Last name	Base Hospital / Institution
Peter	Dolman	University of British Columbia
John	Wade	University of British Columbia

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