Midline Destructive Lesions in a Cocaine User
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A 44-year-old man with a history of cocaine use presented with a 1-year history of headache and progressive frontal-lobe syndrome. Physical examination revealed ophthalmoparesis that was due to mechanical restriction of eye movements, mild unilateral (right) pyramidal tract signs, and a defect in the palate (Panel A). Computed tomography revealed extensive destruction of the osteocartilaginous structures of the nasal cavity (Panel B). Magnetic resonance imaging revealed extensive edema of the frontal lobes (Panel C shows a T2-weighted image) and extensive meningeal and frontal-lobe enhancement. Laboratory testing revealed a positive serum test for antineutrophil cytoplasmic antibody and normal cerebrospinal fluid. Bacterial and fungal cultures of tissue were negative. Histopathological examination revealed chronic inflammation, which can be seen in the case of cocaine use or granulomatosis with polyangiitis. However, no pathognomic lesions that were suggestive of granulomatosis with polyangiitis were seen. Cocaine-induced midline destructive lesions may be the result of a necrotizing inflammatory tissue response that is triggered by cocaine use...

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