Nasal septum perforation in patient with pyoderma gangrenosum

Int. Arch. Otorhinolaryngol. 2012;16(2):278-281. DOI: 10.7162/S1809-97772012000200018 Case Report Nasal septum perforation in patient with pyoderma gangrenosum Perfuração de septo nasal em paciente com pioderma gangrenoso Camilla Bezerra da Cruz Maia1, Felippe Felix2, Vania Paes3, Julia Alves de Azevedo4, Eliza Raquel Negrão Grangeiro5, Jonatah Lucas N. Riccio4, Helen Cruz Rito4. 1) Resident Doctor of Otolaryngology. 2) Master for the UFRJ. Doctor of the Department of Otolaryngology of the State Serving Hospital, Health department, Rio de Janeiro. 3) Medical Teacher of the Hospital of the State Server. 4) Resident Doctor (a) of Otolaryngology of the Hospital of the State Server, Health department, Rio de Janeiro. 5) Resident Doctor of Dermatology of the Hospital of the State Server, Health department, Rio de Janeiro. Institution: Hospital of the Servers of the State of Rio de Janeiro. Rio de Janeiro / RJ - Brazil. Mailing address: Camilla Bezerra da Cruz Maia - Sacadura Cabral Street, 178 - Anexo 4 - Saúde - Rio de Janeiro / RJ - Brasil - Zip-code: 20221-903 - E-mail: Article received in February 3, 2010. Article approved in October 29, 2010. SUMMARY RESUMO Introduction: The cocaine is obtained from the leaves of the coca (Erythroxylon coca). It can be used in many ways, but the most common is the drug inhalation. The Cocaine also causes vasoconstriction at nasal mucous membrane and its chronic use can cause necrosis and nasal septum perforation. Pyoderma gangrenosum is an uncommon idiopathic disease characterized by ulcerations, usually observed on the legs. Its diagnosis is most common an exclusion of others diseases. So far, there is no specific treatment based on evidence by randomized controlled trials. Objective: Describe the rare association between Pyoderma gangrenosum and cocaine. Case Report: E. A., 27-year-old woman with destruction of nasal septum and palate who has been using a big amount of cocaine, been necessary note the difference from which disease cause de damage. Final Comments: Also there are only three cases of Pyoderma gangrenosum complicated with nasal septum perforation in cocaine users. Keywords: pyoderma gangrenosum, nasal septum, diagnosis. Introdução: A cocaína é extraída das folhas do arbusto da coca (Erythroxylon coca), podendo ser consumida de várias formas, mas o modo mais comum é pela aspiração da droga, sendo absorvida pela mucosa nasal, causando vasoconstricção, levando o seu uso crônico à perfuração de septo nasal. Pioderma gangrenoso é uma doença inflamatória rara, idiopática que se caracteriza pela presença de úlceras destrutivas principalmente em membros inferiores. Seu diagnóstico clínico é muitas vezes de exclusão. Objetivo: Descrever a raridade de associação entre Pioderma Gangrenoso e cocaína. Relato de Caso: E. A., 27 anos, com apresentação atípica de Pioderma Gangrenoso com perfurações de septo nasal e palato duro usuária de grande quantidade de cocaína, sendo necessário diferenciar qual patologia causou esse dano. Comentários Finais: Além da necessidade dessa diferenciação, apenas existem três casos relatados na literatura, envolvendo o Pioderma Gangrenoso complicado com perfuração de septo nasal em usuários de cocaína. Palavras-chave: Pioderma Gangrenoso; Septo Nasal; Diagnóstico Int. Arch. Otorhinolaryngol., São Paulo - Brazil, v.16, n.2, p. 278-281, Apr/May/June - 2012. 278 Nasal septum perforation in patient with pyoderma gangrenosum. Maia et al. INTRODUCTION The cocaine it is a extracted alkaloid gives to plant do Erythroxylon gender, Andean and Amazon cultivated shrub command post region. Its dependence possible must to its psychostimulants properties and local anesthetic action. Under the hydrochloride form it is managed by different ways, being able to be inhaled and to be absorbed by the nasal mucous what cause vasoconstriction of nasal arterioles, taking the necrosis and perforation of nasal septum with the drawn out use. Already the Pyoderma Gangrenosum is a rare, chronic, pertaining dermatosis to the specter of the neutrophil dermatosis that is reactive inflammatory processes (1). For being a rare, recognized illness individually only in century XX for BRUNSTING et al. (2), its incidence is difficult to determine, since the published cases are generally isolated or with small number of sick people (3). Generally the injuries are multiple and the skin of the inferior members is the reached place more. In 50% to 70% of the patients, associate it a base illness, as intestinal inflammatory illness, rheumatic, hematologic illness or malignancy (3,4). However, the association of Pyoderma with cocaine, as in this in case that physician, were described in only three stories of case in literature. Figure 1. Ulcer of face before the treatment. The case to be related is about a patient with Pyoderma Gangrenosum diagnosised after exclusion of the too much auto-immune illnesses; however its form of presentation atypical and rare must in such a way to the condition of the face how much to the use of cocaine associated with the base pathology. Figure 2. Face ulcer after treatment. CASE REPORTS E.A., 27 years, feminine sex, medium brown, divorced, of the home, natural and coming from Rio de Janeiro, presenting it has 5 years left half-face ulcer that it evolved for inferior members, hard palate and complete destruction of nasal septum. It affirms to be using of great amount of cocaine per 10 years. In the physical examination, it presented face with edge ulcer badly delimited and erythematosus base with purulent pardon with some epithelized edge areas, occupying, practically, all left half-face. In inferior members, injury ulcerated in right leg. No longer otolaryngologic examination, there was in the previous rhinoscopy destruction of all nasal septum without areas of inflammatory process and in the oroscopy perforation of hard palate. The otoscopy was normal. It became endoscopy nasal visualizing ample septum perforation, mucous complete without aspect of active infection and presence of residues of mucus (Figures 1 to 6). Figure 3. Nasal perforation of septo (1). Int. Arch. Otorhinolaryngol., São Paulo - Brazil, v.16, n.2, p. 278-281, Apr/May/June - 2012. 279 Nasal septum perforation in patient with pyoderma gangrenosum. Maia et al. In the laboratory examinations, did not evidence systemic illness associate. Anti-HTLV1 and 2 negatives; Ac anti DNA, anti - RNP, C3, C4, FAN, Anti-Ro, Anti-cardiolipin IgM and IgG, PCR and FR inside of the normal values; PPD: 4mm. Swab of ulcerated injury of skin became, having as resulted S. Aures. Biopsy of skin of the face, being suggestive of Pyoderma Gangrenosum and of fragment of mucous of hard palate: ulcerated chronic inflammatory process with necrosis. Figure 4. Nasal perforation of septo (2). In the treatment, the analgesic use was carried through for pain. Vidisic gel in left eye, since it was without lubrication due to extensive injury. Bandage with silver (...truncated)