Blow

A 59-year-old woman presented with right periorbital frontal headache and vertical binocular diplopia. Computed tomography (CT) angiography of the head and neck with contrast was negative. C-reactive protein was 7.3 mg/dL (normal, <0.9 mg/dL) and erythrocyte sedimentation was 79 mm/hr. Despite a negative temporal artery biopsy, she was treated for biopsy-negative giant cell arteritis. Symptoms worsened over time. A review of the initial CT demonstrated paranasal sinus disease and a mass in the right medial orbit with disruption of the medial orbital wall. Magnetic resonance imaging showed an enhancing lesion in the inferomedial portion of the right orbit associated with opacification and enhancement of the right ethmoid, maxillary and frontal sinuses. Antineutrophil cytoplasmic antibodies (ANCA) were negative for myeloperoxidase (perinuclear ANCA) but positive for proteinase 3 (cytoplasmic ANCA). An intranasal biopsy demonstrated a nonspecific ulcer site reaction with a mixed inflammatory cell composition and focal vascular injury. Upon further questioning, the patient admitted to intranasal insufflation of cocaine confirming the diagnosis of cocaine-induced midline destructive lesions.