The prevalence of
cocaine use is rising worldwide, with a resultant rise in associated pathology. Regular nasal use can cause
cocaine-induced midline destructive lesions (CIMDL), which can be difficult to distinguish from ear, nose, and throat (ENT)-limited
Wegener's granulomatosis (WG). Two
cocaine users presented with mid-
facial pain,
epistaxis, and systemic symptoms. Both had
nasal septal perforation,
necrosis of sinus mucosa, and positive
anti-neutrophil cytoplasmic antibodies (
ANCA). Histology was inconclusive and treatment with immunosuppressive drugs was commenced. The first patient continued to use
cocaine initially, with improvement in her symptoms only on high doses of
steroid. Later she stopped
cocaine and this plus a switch from
cyclophosphamide to
mycophenolate mofetil resulted in successful symptom resolution and
steroid withdrawal. The second patient denied
cocaine use but having only partially responded to high-dose
prednisolone and
methotrexate, she admitted continued
cocaine use and was lost to follow-up. Evaluation of a patient with destructive lesions of the mid-face should include enquiry about intranasal use of
cocaine. Localized ENT involvement, inconsistent
ANCA pattern, and atypical biopsy findings for WG should be recognized as features of CIMDL. Although cessation of
cocaine use is crucial, there may be a role for immunosuppression.