The prevalence of cocaine adulterated with levamisole-induced vasculitis is increasing and physicians should be aware of this unique entity. There have been many reports of cutaneous vasculitis syndrome caused by cocaine which is contaminated with levamisole. Levamisole was used as an antihelminth drug and later was rescinded from use in humans due to adverse effects. Through this paper, we will report a 39-year-old crack cocaine user who presented with purpuric rash and skin necrosis of his ear lobes. Levamisole-induced vasculitis syndrome was suspected. A urine toxicology screen was positive for cocaine, opiates, and marijuana. Blood work revealed positive titres of ANA and p-ANCA, as well as anti-cardiolipin antibody. Biopsy taken from the left ear showed focal acute inflammation, chronic inflammation with thrombus formation, and extravasated blood cells. Treatment was primarily supportive with wound care. 1. Introduction Levamisole, which was first developed as an antihelminth agent in the 1960s [1], can result in toxicity from the use of adulterated cocaine. It is an increasing reported cause of agranulocytosis, vasculopathy, and skin manifestations like specific rash and skin necrosis [2]. In this report, we describe the case of a 39-year-old crack cocaine user who presents with this unique thrombotic vasculitis, purpuric lesions, and skin necrosis of the ear lobes related to levamisole toxicity. 2. Case Presentation A 39-year-old man with past medical history of cocaine abuse, gout, attention deficit hyperactivity disorder, and hand cellulitis secondary to methicillin-resistant Staphylococcus aureus (MRSA) infection presented with painful lesions on his right hand, left foot, and bilateral ears. Onset was three days prior to presentation where he started to have a constant burning sensation, most severely on the superior aspect of his ears. He had last smoked cracked cocaine one day prior to presentation and he was snorting it the day before. On admission, the patient was afebrile, with blood pressure of 125/83？mmHg and heart rate of 110 beats per minute. On examination, the blisters on the dorsum of the right hand were new, although there was still an open wound from hand cellulitis secondary to MRSA infection 4 years ago on the dorsum of the second metacarpophalangeal joint. There was also a dry, closed, and scaly lesion on the left foot, as well as black necrotic bilateral auricular lesions with 1-2？mm blisters noted on both ears (Figure 1). The tongue had a hard nonerythematous nodule on the center, tender to touch. The rest of the physical
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