17 April 2026
: Case report 
Cocaine–Levamisole-Associated Vasculopathy Mimicking ANCA-Associated Vasculitis and Presenting With Pulmonary–Renal Syndrome Requiring VV-ECMO Support
Challenging differential diagnosis, Unusual setting of medical care, Rare disease
Zahra Vaezi
ABCDEFG 1*, Afshin Amini ABCDEFG 1
DOI: 10.12659/AJCR.951159
Am J Case Rep 2026; 27:e951159
Table 1 Summary of clinical presentation, diagnostic findings, treatment course, and outcomes.This table provides an overview of the patient’s initial symptoms, key laboratory abnormalities, imaging findings, renal biopsy results, and toxicology screen, along with the sequence of immunosuppressive therapies (pulse corticosteroids, rituximab, plasmapheresis, cyclophosphamide) and supportive interventions, including VV-ECMO. A row describing bronchoscopy-confirmed diffuse alveolar hemorrhage has been added to align with the case narrative.
| Parameter | Patient value | Normal range | Interpretation |
|---|---|---|---|
| Age/sex | 30-year-old female | – | – |
| Presenting symptoms | Fatigue, dyspnea, hemoptysis | – | Pulmonary involvement |
| Vital signs on admission | HR 112 bpm, BP 116/74 mmHg, Temp 36.5°C, SpO 96% RA | HR 60–100 bpm, BP 90–140/60–90 mmHg, Temp 36–37.5°C, SpO >94% | Tachycardia |
| Hemoglobin | 5.8 g/dL | 12.0–16.0 g/dL | Severe anemia |
| White blood cell count | 4.8×10/μL | 4.0–11.0×10/μL | Normal |
| Platelet count | 422×10/μL | 150–400×10/μL | Thrombocytosis |
| Potassium | 2.4 mmol/L | 3.5–5.1 mmol/L | Hypokalemia |
| Creatinine | 1.5 mg/dL | 0.6–1.1 mg/dL | Acute kidney injury |
| BUN | 16 mg/dL | 7–20 mg/dL | Normal |
| CRP | 5.1 mg/L | <9 mg/L | Mild inflammation |
| Anti-MPO antibody | >8.0 U | <0.9 U | Strong positive |
| Anti-PR3 antibody | 1.2 U | <0.9 U | Low positive |
| c-ANCA titer | >1: 640 | Negative (<1: 20) | Strong positive |
| p-ANCA titer | >1: 640 | Negative (<1: 20) | Strong positive |
| ANA | Negative | Negative | Negative |
| Anti-GBM antibody | <0.2 | <0.9 | Negative |
| Urinalysis | Proteinuria (141 mg/dL), microscopic hematuria, RBC casts | Protein <12 mg/dL | Active urine sediment |
| Toxicology | Positive for cocaine, oxycodone | Negative | Drug exposure identified |
| Renal biopsy | Necrotizing and crescentic GN | – | Pauci-immune GN consistent with AAV |
| Chest CT | Extensive pan-lobar infiltrates | – | Compatible with pulmonary hemorrhage |
| Bronchoscopy | Bloody BAL aliquots, clot in RUL | – | Confirmed DAH |
| Treatment | Pulse IV methylprednisolone ×3 days → prednisone 60 mg daily; rituximab weekly ×4; cyclophosphamide ×1; plasmapheresis ×7; VV-ECMO | – | Aggressive induction |
| Outcome at 18 months | Creatinine 0.8 mg/dL, resolved proteinuria, minimal residual lung changes, persistent MPO-ANCA positivity | – | Clinical remission |