Extensive cocaine-induced necrotizing midline destructive lesion

Abstract

Differential diagnosis of destructive midline injuries is complex due to its nonspecific cli- nical presentation, and the broad variety of conditions that share the same signs and symptoms, such as infections, neoplasms and autoimmune diseases. One of the etiologies that should be considered is cocaine-induced destructive midline lesions (CIMDL), cha- racterized by extensive destruction of midface structures. The following case describes a patient with history of cocaine abuse with a large destructive endonasal lesion asso- ciated with a palatal perforation, fever, cervicalgia and meningism. Clinical assessment included a nasofibroscopy and laboratory tests. Results revealed a slight increase in in- flammatory parameters and positive antineutrophil cytoplasmic antibody serology. Ad- ditionally, imaging revealed a thrombosis of the right internal carotid, clivus osteitis, and retroclival pachymeningitis. Surgical debridement was performed, and biopsies of the nasal cavity were taken. Once the other possible diagnoses were ruled out, the patient was started on intravenous antibiotic and antifungal therapies. The patient showed a positive response to treatment and was successfully discharged after two months. CIMDL is a rare condition whose main differential diagnosis is granulomatosis with polyangiitis. Given the similarity in clinical presentations and the important differences in the management of both pathologies, the need for an accurate diagnosis is essential.