Cocaine-Induced Midline Destructive Lesions: A Real Challenge in Oral Rehabilitation

Granulomatosis With Polyangiitis Presenting As Orbital Apex Syndrome

Granulomatosis with polyangiitis (GPA) is a rare small-vessel vasculitis that typically presents with a triad of sinonasal, pulmonary, and renal symptoms. Here, we present the case of a 43-year-old female with a history of substance use disorder who presented with vision changes and worsening left eye pain over five days. Previous evaluations raised concerns about GPA versus cocaine-induced vasculitis, but diagnostic confirmation was hindered by a lack of medical follow-up. Prompt multidisciplinary intervention led to significant improvement following steroid therapy and IV antibiotics, and the patient was ultimately diagnosed with a high GPA. This case highlights the complexities involved in diagnosing and managing GPA presenting as orbital apex syndrome, particularly in patients with comorbidities and non-adherence to medical follow-up.

Cutaneous and Mucosal Conditions Associated With Cocaine Use

Cocaine and some of its main adulterants, such as levamisole, can cause multiple cutaneous and mucosal manifestations, including ischemic complications, neutrophilic dermatoses, midline destructive lesions, and vasculitis associated with antineutrophil cytoplasmic antibodies (ANCAs). Striking systemic symptoms are generally not seen. In all these conditions, positive test results may be observed for antinuclear antibodies, antiphospholipid antibodies, and various ANCAs, sometimes with characteristic staining patterns. Histology typically shows vascular changes, such as leukocytoclastic vasculitis, necrotizing vasculitis, and thrombi. We review the clinical, serologic, and histologic features of cutaneous and mucosal conditions associated with the use of cocaine and also look at pathophysiologic mechanisms, differential diagnoses, and treatments.

[Translated article] Cutaneous and Mucosal Conditions Associated With Cocaine Use

Cocaine and some of its main adulterants, such as levamisole, can cause multiple cutaneous and mucosal manifestations, including ischemic complications, neutrophilic dermatoses, midline destructive lesions, and vasculitis associated with antineutrophil cytoplasmic antibodies (ANCAs). Striking systemic symptoms are generally not seen. In all these conditions, positive test results may be observed for antinuclear antibodies, antiphospholipid antibodies, and various ANCAs, sometimes with characteristic staining patterns. Histology typically shows vascular changes, such as leukocytoclastic vasculitis, necrotizing vasculitis, and thrombi. We review the clinical, serologic, and histologic features of cutaneous and mucosal conditions associated with the use of cocaine and also look at pathophysiologic mechanisms, differential diagnoses, and treatments.

Long-term Results of Three-layered Closure of Oronasal Fistula: A Case Report

An oronasal fistula is an interconnection between the oral and nasal cavities. It interferes with normal functioning and affects quality of life by impeding eating and speech. The most common management strategy is surgical treatment. The aim of our study was to present the results of a long-term follow-up of effective treatment of a case of oronasal fistula that occurred without any cause and comorbidities. A 46-year-old woman reported the sudden appearance of a painless oronasal fistula. She demonstrated nasal regurgitation—that is, loss of fluids through the nose while drinking—and slurred‚ nasal speech. Clinical examination revealed a soft tissue defect (diameter: 5 mm) on the left side of the palate. Computed tomography revealed a gap in the hard palate bone, measuring 25 × 30 mm. No complications were noted following the procedure, nor at 10-year follow-up. It seems that the use of bone substitute and palatal flap for spontaneous oronasal fistula closure was fully justified. The patient may have had an undiagnosed congenital defect of the hard palate, and the deficit may have appeared due to bone loss occurring in her forties. However, no consensus exists regarding the best treatment management for oronasal fistulae located in the palatal region, and further comparative studies between the existing techniques are needed.

Cocaine-Induced Midline Destructive Lesions (CIMDL): A Real Challenge in Diagnosis

The prolonged use of intranasal cocaine can destroy the nasal architecture with the erosion of the palate, turbinates, and ethmoid sinuses causing cocaine-induced midline lesions (CIMDL). The CIMDL display a clinical pattern mimicking variable diseases. The aim of this study was to highlight the difficulties in reaching a correct diagnosis through the evaluation of eight new cases. The diagnostic procedures followed in these patients included: detailed medical history, clinical and histological examination, computed tomography and magnetic resonance imaging, laboratory findings (complete blood count, sedimentation rate, antinuclear antibody test, rheumatoid factor, venereal disease research laboratory test, leishmaniasis and fungal serology, antineutrophil cytoplasmic antibodies ANCA test), and chest X-ray. All patients complained of epistaxis, halitosis, nasal scabs and obstruction, decreased sense of smell and/or taste, oro-nasal regurgitation of solids and liquids with recurrent sinus infections, and chronic facial pain. On clinical examination, all patients showed palate perforation with variable nasal structure involvement and presented a strong positivity for ANCA tests with a p-ANCA pattern. The followed protocol for the CIMDL diagnosis allowed for a relatively quick and conclusive diagnosis in all patients. A multidisciplinary approach is mandatory in the management of CIMDL, involving dental professionals, maxillofacial surgeons, and psychologists.