case_images: PMC4849970_01
case_images: Skin lesions: A, Retiform purpura with a small area of
  necrosis in the right earlobe (pre-treatment). B, Residual skin
  lesions in the right earlobe after 3 weeks of immunosuppressive treatment.
  C, Purpuric violaceous lesions with surrounding erythema in
  the lower limb. Skin biopsy: D, Immunohistochemistry with
  anti-CD61 antibody showing positive staining for thrombi inside the vascular
  lumen, with surrounding inflammation of the vessel wall (magnification 100x).
  E, Small vessel vasculitis with neutrophilic inflammation and
  leukocytoclasia (H&E, magnification 100x).
case_images: 1414-431X-bjmbr-1414-431X20165244-gf001.jpg
case_images: PMC4849970_01_1414-431X-bjmbr-1414-431X20165244-gf001.jpg
case_images: f01
case_images: The auricula was edematous and purpuric, with focal necrosis, as shown in Figure 1. Skin biopsy revealed a neutrophilic vasculitis in small vessels with eosinophils, leukocytoclasia, and fibrinoid necrosis (Figure 1).
case_images: Kidney biopsy: A, Chronic tubulointerstitial inflammatory
  infiltrate composed mainly by lymphomononuclear cells (H&E, 100x
  magnification). B, The glomerulus exhibits a cellular crescent
  and mesangial hypercellularity (H&E, 400x magnification). C,
  Multifocal rupture of the glomerular basement membrane, with a cellular crescent
  in the Bowman's space (methenamine silver, 400x magnification).
case_images: 1414-431X-bjmbr-1414-431X20165244-gf002.jpg
case_images: PMC4849970_01_1414-431X-bjmbr-1414-431X20165244-gf002.jpg
case_images: f02
case_images: Podocyte hypertrophy, focal mesangiolysis, a diffuse and chronic inflammatory infiltrate in the tubulointerstitium, and interstitial fibrosis and tubular atrophy in 10% of total cortical area were also observed (Figure 2).
case_images: Evolution of renal function over 3 months of follow-up and its relation to
  urine toxicology for cocaine and levamisole, and to therapeutic interventions
  (methylprednisolone and cyclophosphamide intravenous (iv)
  pulses).
case_images: 1414-431X-bjmbr-1414-431X20165244-gf003.jpg
case_images: PMC4849970_01_1414-431X-bjmbr-1414-431X20165244-gf003.jpg
case_images: f03
case_images: One month after hospital discharge, the patient reported abstinence from cocaine, which was confirmed by negative urine samples for cocaine or levamisole, and exhibited progressive improvement of renal function (Figure 3).