Nasal septal perforation in systemic lupus erythematosus

A 40-year-old female with systemic lupus erythematosus was admitted with typical characteristics of active lupus in the form of palatal ulcers, alopecia, bicytopenia, lupus nephritis (class 4), necrotizing lymphadenopathy, high-titer anti-double-stranded deoxyribonucleic acid, and low complements. P-ANCA and C-ANCA tests performed using ELISA method were negative. Otorhinolaryngology opinion was taken for nasal block, and a diagnostic nasal endoscopy showed a large septal perforation involving the anteroinferior and anterosuperior parts of the cartilaginous nasal septum with severe crusting over the edges of the septal perforation. The crusts were endoscopically cleared, edges of the perforation were smeared with an antibiotic cream, and the patient started the use of saline nasal douches. She was treated with pulse methylprednisolone, mycophenolate mofetil, hydroxychloroquine, and other supportive medications. The patient attained remission over time, and periodic endoscopic examination showed the perforation to be stable in size and free of major crusting (Figure 1). Nasal septal perforation is an underdiagnosed complication of lupus because it is asymptomatic and the patients are often not aware of their nasal problem (1). Nasal septal perforation in lupus may be secondary to vasculitis or to ischemia with subsequent chondrolysis (2). Treatment should primarily be directed to control disease activity.

Figure 1.

Large septal perforation involving the anteroinferor and anterosuperior parts of the cartilaginous nasal septum