Heroin-induced nasal necrosis and septal perforation

We present the case of a 44-year-old woman with a 28-year history of intranasal heroin use who developed severe necrosis of the nasal mucosa and septal perforation. She denied any prior insufflation of cocaine or other substances. Necrosis of the septum was recurrent and persistent despite repeated debridement. Necrosis and perforation of the nose and palate are well-described consequences of intranasal cocaine abuse, often attributed to cocaine’s vasoconstrictive properties. However, there have been few reports of similar effects associated with heroin. This case and other recent reports of non-vasoconstrictive substances causing nasal and palatal necrosis suggest that vasoconstriction alone may be an incomplete explanation for the pathogenesis of cocaine induced midline destructive lesions (CIMDL). Cocaine and other recreational drugs, including heroin, may cause midline destruction through a common non-vasoconstrictive mechanism, possibly mediated by antineutrophil cytoplasmic antibodies.