P042 Cocaine-associated plasma cell orificial mucositis

Abstract

A 37-year-old man presented with a 3-month history of ulceration and inflammation affecting the infranasal upper cutaneous lip. This was unresponsive to repeated oral flucloxacillin and topical antibiotics prescribed in the community for presumed impetigo. His medical history included excessive alcohol use and depression, treated with sertraline, lansoprazole and thiamine. He denied recreational drug use initially. Examination revealed overgranulated ulcerative plaques infranasally and nasal rim inflammation, but he was otherwise systemically well. Investigations showed a normal autoimmune screen and serum angiotensin-converting enzyme, but elevated perinuclear antineutrophil cytoplasmic antibodies (ANCA) titres (1 : 640), with negative myeloperoxidase ANCA and proteinase 3-specific ANCA. An incisional biopsy of the skin demonstrated severe acute-on-chronic, plasma-cell-dominated inflammation, without vasculitis or ­granulomatous change. Persistent questioning revealed regular, heavy cocaine insufflation. The patient was counselled to cease drug use and was offered referral to rehabilitation, which he declined. Subsequent review by ear, nose and throat specialists was unsuccessful due to nonattendance. Upon follow-up, significant improvement was observed; however, the patient reported experiencing septal collapse. Despite continued use of cocaine, the patient had notably reduced both the amount and frequency of use. Cocaine-induced nasal mucosal damage and septal perforation are well documented. However, a newly described entity, cocaine-associated plasma cell orificial mucositis (PCOM), is characterized by plasma-cell-rich inflammation of the nostrils and upper lip. PCOM is a benign but potentially disfiguring and distressing condition that may cause ulceration, crusting and septal damage. Recognition of this association is important for diagnosis and management.