Drug Induced Midline Destructive Lesion and ANCA positive Vasculitis


Qutab Shah, Sonia Sundanum, Aine Gorman, Angela Camon, Eileen Shinners, Ausaf Mohammad and Killian O’Rourke


Department of Rheumatology, Midland Regional Hospital Tullamore


We describe a case of a 24 years old male who was first seen in Rheumatology opd in March 2019 with a two years history of recurrent nasal obstruction, crusting, bleeding, nasal infections (Vestibulitis) and rhinosinusitis which responds partially to oral steroids / oral antibiotics / nasal sprays. However he feels that symptoms resolve mostly with oral steroid administration. He denied history of dry eyes, dry mouth, oral ulcers, paraesthesia of arms and legs, significant sputum production, symptoms suggestive of synovitis, vasculitic rash, or nail fold changes. He also reported weight loss of 9 kg and night sweats in recent months. His medical background history included childhood asthma and active heavy smoking. List of medication at included Prednisolone 15mg OD (On a reducing course to 0). Fluticasone Inhaler, Bactroban nasal ointment, and Montelukast. Family history was negative for inflammatory joint disease, Vasculitis and connective tissue disease. On physical examination he had some acneform lesions in his upper chest.There were no vasculitic lesions anywhere on the hands and feet. Cardiovascular, pulmonary and abdominal examination was unremarkable. He had some tenderness around his nose and sinuses on palpation. There was no lymphadenopathy. His nose did not look particularly erythematous but it did look enlarged. Lab investigations showed negative ANA, RF, anti-CCP, HLA B27, IgA, IgM, and normal C3, C4, U&E, LFTS, HB but abnormal WCC 18.4 (nr<4) Neut 14.14 (nr<7), Eosinophils 0.75, Globulins 39.8 (nr<30), CRP 105.4, ESR 52 and positive ANCA (atypical P-ANCA) PR3 positive, titre 6.4 (nr<3) and MPO negative, Urinalysis was normal. CT scan of brain, thorax, abdomen and pelvis was normal. CT sinuses showed findings consistent with moderate to severe sinusitis involving maxillary and ethmoid sinuses. It also showed severe destruction of the nasal septum anteriorly and the mid-section with some preservation posteriorly.Nasal biopsy of the left middle turbinate, inferior left turbinate, left superior turbinate, septum and left nasal vestibule shows inflamed granulation tissue with eosinophils in most of these biopsies. No evidence of dysplasia, malignancy. No evidence of granuloma. History of Cocaine usage noted by GP previously and patient admitted to having used Cocaine frequently.Urine Toxicology screen was also noted positive for Cocaine at one occasion at GP in February 2019. Patient was explained his diagnosis of Cocaine induced nasal cartilage destruction and ANCA positivity and that only treatment is cessation of Cocaine administration.
Cocaine induced midline destruction and ANCA positive vasculitis has been previously reported in number of case studies. There is known association between the ingestion of levamisole-contaminated cocaine and ANCA-associated systemic autoimmune disease. Further details will be discussed.