Ulcers in a Past Drug User

by chelseajin

Because I am a genius, I threw out the notes I had taken while doing rounds with the Family Medicine residents. So I’ll have to rely on memory to write this up.

One of the more interesting people we saw was a woman in her thirties who came to the hospital because of recurring ulcers that were becoming very painful. She actually had these sores for the past 3 years, mostly on the upper body, but they hadn’t bothered her enough until recently.

She had several open sores on both of her legs, the largest being around 2 inches wide. They weren’t actively bleeding, but they had some pus and had a red inflamed border. She some more on her arms and ears, and told us they were also starting to develop on her chest. She also complained of painful genital ulcers.

The team had spoken to her before and found that she had a past (questionably) history of cocaine use. Lab tests showed that she was positive for a Naficillin-sensitive Staph. Aureus infection and syphilis.

She had no fever. No rash. No HIV or any other STDs.


The doctors seemed baffled by the sores. When we sat to discuss our differentials, the attending looked to the pharmacist for some advice. The neat thing about this system is that it takes pressure off the MDs to know the drugs inside and out. She brought out a paper which was titled something along the lines of Levamisole-Cocaine dermatological effects. I actually came across the same one as I was doing some searches on my phone for clues to what was afflicting the patient.

Levamisole is an anti-helminthic (anti-worm medication) which is now being used to cut cocaine. Ingestion is causing ulcers and rashes to come up. Starting from around this past summer, it seems to be a “popular” agent to cut the drugs with and has been cropping up case reports from many hospitals.

The pictures seem to follow this trend of deep purple bruising patterns and some ulceration (but not much from what I can see). I don’t think that’s what the patient has, and I don’t think her CBC reflected the changes that these reports are saying: lowered white blood cell count with autoantibodies.


She did acknowledge that she had gotten syphilis a while back and said she got a penicillin shot for it, but now we’re not sure how long she’s had the current infection since the tests for syphilis are based on antibodies and can’t tell us about re-infections.

Syphilis is my favorite STD.

It gets this title because it’s smart. It causes painless lesions which go away and eventually causes neurodegenerative disease. If you want to stay inside your host, you shouldn’t cause it too much trouble!

It has a unique pathogenesis, going through 3 stages:

Primary: a single, painless skin ulceration commonly found in the cervix, penis, or anus. Adenopathy around the site.

Secondary: 4-10 weeks after primary infection, a maculopapular/pustular (flat and bubbly) rash on the trunk, palms, and soles.

Tertiary: Years down the line, you can get “gummas”, tumor-like grows, or neurosyphilis, causing neurodegeneration. The effects of this range from paralysis or loss of sensation in some areas to Argyll Robertson pupils (don’t constrict in light).

The End

She probably has a whole slew of problems, maybe a chancroid (to explain the painful genital ulcers), with preexisting syphilis, and neutropenia because of chronic cocaine use. I’ll be skimming through some of these other articles which discuss atypical presentations of syphilitic ulcers, and who knows, that could be part of her problem.

I’m requesting an article through the library on ulcer presentations and maybe that’ll be useful, but by that time I’m sure the woman will be released with steroids or antibiotics.


Levamisole-Adulterated Cocaine: A Case Series. Journal of the American Board of Family Medicine.