SHM Converge Scientific Abstract ePoster Gallery-Nasopharyngeal Ulceration: Unraveling the Mystery of Seronegative Granulomatosis With Polyangiitis vs. Intranasal Opioid Use Complications- A Case Report

Nasopharyngeal Ulceration: Unraveling the Mystery of Seronegative Granulomatosis With Polyangiitis vs. Intranasal Opioid Use Complications- A Case Report

Back to course

Pdf Summary

This case report describes a 31-year-old man with presumed granulomatosis with polyangiitis (GPA) who presented with progressive mouth and nasopharyngeal ulceration, hemoptysis, dyspnea, pneumonia, and bilateral leg DVTs. He had a history of severe intranasal oxycodone use and had been taking chronic prednisone for months based on an unconfirmed GPA diagnosis.<br /><br />Imaging showed extensive destruction of the nasal cavity and posterior nasopharynx, initially raising concern for mucormycosis. However, infectious disease and ENT teams felt mucormycosis was unlikely because of the slow progression and lack of neurologic symptoms. Rheumatology then re-evaluated the GPA diagnosis, noting that prior biopsy and serologic testing had been incomplete and inconclusive.<br /><br />Further workup included ANCA, rheumatoid factor, proteinase 3 testing, urine studies, and a posterior oropharyngeal biopsy. Serologies were negative, and pathology revealed necroinflammatory debris with fungal elements consistent with Candida, but no vasculitis. During biopsy, exposed bone and cervical MRI findings raised concern for C1 osteomyelitis, though biopsy confirmation was too risky. The patient was treated with prolonged antifungal therapy.<br /><br />The authors emphasize that GPA should be diagnosed using a combination of clinical, serologic, and histopathologic evidence to avoid unnecessary long-term steroid exposure and its complications, such as immunosuppression, hypertension, and diabetes. In this patient, the nasal destruction and saddle-nose changes may have been related to chronic intranasal opioid use, possibly compounded by xylazine-adulterated street opioids, which can cause ulcerative lesions. Chronic prednisone likely worsened his immunocompromised state, enabling invasive Candida infection and possible spread to the cervical spine.<br /><br />Overall, the case highlights the importance of careful diagnostic confirmation before labeling destructive nasal disease as seronegative GPA.

Asset Subtitle

Aamila Shaik

Meta Tag

Author List Aakhila Rameeza, Aamila Shaik, Joseph Grogg

Category Clinical Vignettes

Concept Granulomatosis with Polyangiitis

Concept ENT Involvement

Concept Nasal Ulceration

Concept Saddle Nose Deformity

Concept Antineutrophil cytoplasmic antibody

Distinguished Non-Finalist

Presenter Organization Cooper Medical School

Presenting Author Aamila Shaik

Track Adult

Keywords

granulomatosis with polyangiitis

GPA

nasopharyngeal ulceration

intranasal oxycodone

chronic prednisone

mucormycosis differential

Candida infection

ANCA negative

nasal cavity destruction

osteomyelitis

Granulomatosis with Polyangiitis

ENT Involvement

Nasal Ulceration

Saddle Nose Deformity

Antineutrophil cytoplasmic antibody