A42-11 Cocaine-associated Pulmonary Embolism and Lung Injury With Atypical P-ANCA Positivity

Abstract Introduction Cocaine use has been linked to vascular and pulmonary complications, including thromboembolism, inflammatory lung injury, and drug-induced vasculitis. Levamisole, a common adulterant in crack cocaine, can trigger autoantibody formation leading to perinuclear anti-neutrophil cytoplasmic antibody (pANCA) positivity and immune-mediated tissue injury. This overlap of thrombotic, infectious, and inflammatory processes poses a diagnostic challenge. We present a case of pulmonary embolism and diffuse lung injury associated with chronic crack cocaine use and high-titer atypical pANCA positivity. Case Report A 36-year-old woman with a history of chronic crack cocaine use, tobacco exposure, and type 2 diabetes presented with tachycardia, low-grade fevers, progressive dyspnea, and cough with blood-tinged sputum. Computed tomography with pulmonary embolism protocol revealed a right upper lobe segmental thrombus and patchy ground-glass opacities. Initial laboratory evaluation demonstrated elevated anti-cardiolipin IgM, beta-2 glycoprotein IgG, and a positive dilute Russell’s viper venom time (DRVVT). High-titer atypical pANCA (1:640) was present, but anti-myeloperoxidase (MPO) antibody was negative. Given the absence of prior thrombotic events or pregnancy losses, antiphospholipid antibody syndrome was deemed unlikely.The patient was treated with apixaban and counseled on cocaine cessation; however, she continued use. Two months later, repeat CT demonstrated resolution of the thrombus but persistent diffuse ground-glass opacities. Infectious testing, including influenza and SARS-CoV-2, was negative. Continued cocaine exposure was confirmed on urine toxicology. With corticosteroid therapy and abstinence support, her respiratory symptoms and imaging findings improved. Conclusion This case uniquely illustrates concurrent thromboembolic and inflammatory pulmonary injury associated with levamisole-adulterated cocaine, highlighting an underrecognized spectrum of cocaine-induced vasculopathy. Levamisole-adulterated cocaine can elicit both vasculitic and hypercoagulable manifestations through atypical pANCA positivity and transient antiphospholipid antibody production, thereby mimicking primary autoimmune or thrombotic disorders. In routine clinical practice, levamisole detection is rarely performed, as it is not included in standard toxicology panels and requires specialized testing with limited availability and a short detection window. Recognition of this entity is therefore critical to prevent unnecessary long-term immunosuppression and to emphasize substance cessation as the cornerstone of management. This abstract is funded by: None