Vasculitis mimics: cocaine-induced midline destructive lesions

Area of Science:

• Rheumatology
• Toxicology
• Pathology

Background:

• Nasal cocaine abuse is known to cause midline destructive lesions.
• These lesions can mimic various conditions, including small-vessel vasculitis.
• Granulomatosis with polyangiitis (Wegener's granulomatosis) is a condition that can be mimicked.

Observation:

• Two patients with a granulomatosis with polyangiitis diagnosis presented with chronic palatal perforation.
• Their condition was refractory to immunosuppressant therapy.
• Both patients tested positive for antineutrophil cytoplasmic antibodies.

Findings:

• Cocaine-induced midline destructive lesions can present similarly to granulomatosis with polyangiitis.
• Antineutrophil cytoplasmic antibody positivity is observed in both conditions, complicating differential diagnosis.
• Misdiagnosis can lead to unnecessary and potentially toxic immunosuppressant therapies.

Implications:

• Increased awareness of cocaine-induced lesions is essential for clinicians, particularly rheumatologists.
• Accurate diagnosis prevents the use of inappropriate and harmful treatments.
• Understanding this mimicry improves patient outcomes by guiding appropriate management strategies.