Purpose

An unusual case of cocaine-induced PR3-ANCA positive granulomatous disease presenting with bilateral necrotising eyelid lesions and facial ulceration, highlighting the diagnostic challenges, and the importance of multidisciplinary approach.

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Methods

A retrospective review patient’s assessments, including clinical findings, laboratory investigations, histopathology and treatment response over the course of management

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Results

A 42-year-old male presented with a two month history of progressive bilateral necrotising granulomatous upper eyelid lesions with ulceration and haemorrhagic crusting, associated with a painful indurated weeping cheek ulcer. Initial treatment with multiple antibiotic regimes produced limited improvement.Histopathology from skin biopsy showed a mixed inflammatory infiltrate with granulomatous features. Serology revealed weakly positive PR3-ANCA. Urine toxicology returned positive for cocaine. Additional history elicited chronic sinonasal symptoms with intermittent epistaxis and cocaine exposure intranasally.Following multidisciplinary assessment by ophthalmology, dermatology and rheumatology teams, the presentation was considered consistent with cocaine-induced PR3-ANCA positive granulomatous vasculitic disease. The lesions responded well to systemic corticosteroids, with relapse following steroids withdrawal. Furthermore, the residual anterior lamellar shortening and lagophthalmos required ongoing ocular surface lubrication.

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Conclusion

Cocaine-induced PR3-ANCA positive granulomatous vasculitic disease may present with atypical periocular manifestations that mimic infective or inflammatory eyelid pathology. In this case, bilateral necrotising eyelid lesions and facial ulceration caused significant diagnostic uncertainty before cocaine-induced disease was identified as the likely underlying aetiology. The diagnosis was supported by clinical history, granulomatous ulceration, sinonasal symptoms, PR3-ANCA positivity, positive cocaine toxicology and marked corticosteroid responsiveness.

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Additional Authors

First name	Last name	Base Hospital / Institution
Dost	Jabarkhyl	Luton and Dunstable University Hospital
Sheryll	Kamat	Luton and Dunstable University Hospital
Naomi	Aloka	Luton and Dunstable University Hospital
Helena	Fawdry	Luton and Dunstable University Hospital
Engin	Akyol	Luton and Dunstable University Hospital
Susan	Sarangapani	Luton and Dunstable University Hospital

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