Recurrent noninfectious preseptal cellulitis secondary to cocaine use and levamisole-associated vasculitis

A 57-year-old man with a history of cocaine dependence presented with acute left-sided preseptal cellulitis preceded by polyarthralgias, fever, and malaise. He endorsed numerous past episodes of alternating right- and left-sided eyelid edema over 10 years, always occurring within 12 hours to 1 week following cocaine use. While in the hospital, he developed worsening eyelid edema with purpura, dactylitis, and ulcerations of his oral mucosa and lower extremity. Laboratory findings were significant for a urine drug screen positive for cocaine, elevated perinuclear antineutrophilic cytoplasmic antibody (p-ANCA) and anti-nuclear antibody (ANA) titers, and elevated SS-A, SS-B, and anti-Smith autoantibodies. An oral prednisone taper was initiated for a presumed diagnosis of levamisole-induced vasculitis with brisk resolution.