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Cocaine-Induced Midline Destructive Lesions (CIMDL) is the progressive destruction of nasal architecture with the erosion of the palate, nasal conchae, and ethmoid sinuses associated with prolonged insufflation, colloquially 'snorting', of Cocaine. The condition begins with erosion of mucusal lining and progress with damage to nasal cartilaginous and bony structures.

CIMDL is also known colloquially as cocaine or coke nose.

Signs and symptoms

Patients with CIMDL present with chronic nasal obstruction, hyposmia, nose bleeding, and severe facial pain. More advanced cases present nasal septal perforation, diffuse necrotizing ulcerative lesions, nasal deformation, and palatal perforation.

Due to its non-specific symptomatology, CIMDL is easily confused with other diseases such as infections, autoimmune, and granulomatous diseases, albeit with some absent systemic symptoms such as fever, arthralgia, myalgia, CIMDL can be differentiated from systemic conditions. Other markers for CIMDL include perinuclear anti-neutrophil cytoplasmic antibody(ANCA) and neutrophil elastase specific ANCA.

Pathophysiology

Although not entirely understood, CIMDL is thought to be caused mainly by the vasoconstricting effects of cocaine, which induces ischemia and subsequent necrosis of the mucosal lining, followed by damage to nasal cartilaginous and bony structures. Cocaine is also capable of inducing apoptosis of epithelial cells in a dose- and time- dependent manner, which may also contribute to the inflammatory tissue response against cocaine.

The insufflation of cocaine crystals may also cause physical trauma to epithelial cells, leading to inflammatory lesions, which may also worsen due to the tendency for patients to physically remove the scabs produced in the damaged tissue, which induces further mechanical damage.

Cocaine is capable of inducing apoptosis of epithelial cells in a dose- and time- dependent manner, which may also contribute to the inflammatory tissue response against cocaine.

Treatment

The only reliable treatment of CIMDL is cessation of cocaine abuse, which is considered a necessary prerequisite for surgical reconstruction. If abstention can be achieved, reconstructive surgery, prosthetics and medical therapy can achieve satisfactory results. Conservative treatment consists of regular saline douches, debridement of necrotic tissue and administration of antibiotics.

References

1. Di Cosola, Michele; Ambrosino, Mariateresa; Limongelli, Luisa; Favia, Gianfranco; Santarelli, Andrea; Cortelazzi, Roberto; Lo Muzio, Lorenzo (2021-07-23). "Cocaine-Induced Midline Destructive Lesions (CIMDL): A Real Challenge in Diagnosis". International Journal of Environmental Research and Public Health. 18 (15): 7831. doi:10.3390/ijerph18157831. ISSN 1660-4601. Archived from the original on 2024-11-24.{{cite journal}}: CS1 maint: unflagged free DOI (link)
2. ^ Nitro, Letizia; Pipolo, Carlotta; Fadda, Gian Luca; Allevi, Fabiana; Borgione, Mario; Cavallo, Giovanni; Felisati, Giovanni; Saibene, Alberto Maria (2022-07-01). "Distribution of cocaine-induced midline destructive lesions: systematic review and classification". European Archives of Oto-Rhino-Laryngology. 279 (7): 3257–3267. doi:10.1007/s00405-022-07290-1. ISSN 1434-4726. PMC 9130192. PMID 35138441.{{cite journal}}: CS1 maint: PMC format (link)
3. ^ Trimarchi, Matteo; Miluzio, Annarita; Nicolai, Piero; Morassi, Maria Laura; Bussi, Mario; Marchisio, Pier Carlo (2006-03-01). "Massive Apoptosis Erodes Nasal Mucosa of Cocaine Abusers". American Journal of Rhinology. 20 (2): 160–164. doi:10.1177/194589240602000207. ISSN 1050-6586.
4. ^ Trimarchi, Matteo; Bertazzoni, Giacomo; Bussi, M. (January 2014). "Cocaine induced midline destructive lesions". Rhinology. 52 (2).
5. Di Cosola, Michele; Ambrosino, Mariateresa; Limongelli, Luisa; Favia, Gianfranco; Santarelli, Andrea; Cortelazzi, Roberto; Lo Muzio, Lorenzo (2021-01). "Cocaine-Induced Midline Destructive Lesions (CIMDL): A Real Challenge in Diagnosis". International Journal of Environmental Research and Public Health. 18 (15): 7831. doi:10.3390/ijerph18157831. ISSN 1660-4601. PMC 8345435. PMID 34360121. {{cite journal}}: Check date values in: |date= (help)CS1 maint: PMC format (link) CS1 maint: unflagged free DOI (link)
6. Trimarchi, M.; Bussi, M.; Sinico, R. A.; Meroni, Pierluigi; Specks, U. (2013-02). "Cocaine-induced midline destructive lesions - an autoimmune disease?". Autoimmunity Reviews. 12 (4): 496–500. doi:10.1016/j.autrev.2012.08.009. ISSN 1873-0183. PMID 22940554. {{cite journal}}: Check date values in: |date= (help)