Bacteria-induced nasal necrosis with negative cultures

A 79-year-old man with liver failure, hypertension and hyperlipidemia presented with a 1.5-month history of progressive nasal crusting and pain on the inside of the nose, advancing into a necrotic columella and philtrum. On rigid endoscopy, debris extended to middle and inferior turbinate to midway posteriorly. Initial culture swabs and CT were negative. The patient underwent endoscopic biopsy of the lesion, with histopathological findings revealing abundant acute inflammation and minute fragments of atypical squamous epithelium, favouring reactive atypia. Non-invasive fungal hyphae were identified. Bacterial cultures revealed Staphylococcus epidermidis, Corynebacterium accolens, Curvularia species and Pseudomonas putida A current literature search failed to find other published cases of P. putida nasal infections. P. putida is generally difficult to isolate on swab culture as the surrounding tissue is necrosed; this case highlights the importance of reconsidering bacterial infection and obtaining a tissue biopsy in the case of non-healing necrotic-appearing tissue with negative culture swab and CT without evidence of mass.