Session: Poster session C

Binocular diplopia in cocaine related nasal septum destruction

Introduction

Chronic cocaine use carries a high risk of nasal septum damage. Orbital involvement has been reported in several cases and a few cases present with intermittent binocular diplopia. With the ever- increasing numbers of cocaine use worldwide, the case presented here today will become increasingly common in our clinic.

 

Methods

This is a case presentation of a 38 year old male with a two weeks history of headache and binocular vertical diplopia for distance and near. He had a 4 year history of cocaine use and stopped using cocaine 1 year ago.

 

Results

Orthoptic examination showed a slight proptosis and marked mechanical restriction on downgaze of the right eye. CT and MRI demonstrated bilateral destruction of the nasal septum and bone erosion of orbital floor (inferomedial) of the right eye and bilateral orbital inflammation around inferior and medial rectus muscles of the right eye.

A biopsy of the nasal mucosa showed necrotizing, non-granulomatous inflammation without evidence of granulomatous vasculitis. Blood examination showed positive C-ANCA/PR3-ANCA and ANA negative. Multiple diagnosis were considered, but positive C-ANCA/PR3-ANCA made cocaine use the most likely cause for the nasal abnormalities.

Various treatment methods were started, including antibiotics, corticosteroids, nonsteroidal anti- inflammatory drugs (NSAIDs), without significant improvement in orbital inflammation. Only the mechanical restriction and diplopia have reduced since the start of treatment.

Metabolites of cocaine were found in urine that indicate active cocaine use, even though he said he wasn’t. This might be the reason why he is not responding well to treatment.

 

Conclusion

Cocaine use can cause serious damage to the nasal septum and should be considered in de differential diagnosis of binocular diplopia, especially when it extends to destruction of the orbital walls and orbital inflammation.

For optimal treatment, psychosocial help should be advised in these types of patients.