Severe Cocaine-Induced Midline Destructive Lesions (CIMDL) Leading to Orbital Apex Syndrome and Peripheral Ulcerative Keratitis

Purpose: To describe a case of cocaine-induced midline destructive lesions (CIMDL) associated with ocular autoimmune disease. Methods: Observational case report. Results: A 45-year-old man with history of chronic osteolytic sinusitis due to cocaine abuse presented with sudden vision loss in right eye. Ophthalmic examination revealed fixed right mydriasis with extraocular movements limitation and optic disc swelling. Computed tomography showed an orbital infiltrating mass. The diagnosis of orbital-apex syndrome secondary to CIMDL was established. Steroids and antibiotics therapy were started without vision improvement. At 6-months follow-up, a corneal ulcer with characteristics of peripheral ulcerative keratitis (PUK) was evidenced, coinciding with an upper respiratory bacterial infection. Conclusions: CIMDL and PUK share common pathogenic pathways, with implication of autoimmune factors and exposure to infective antigens. We hypothesized that chronic cocaine use, along with persistent bacterial infection, could have triggered an inflammatory reaction, which contributed to CIMDL development and the appearance of PUK.

Automated summary

This case report describes a patient with CIMDL and ocular autoimmune disease likely triggered by chronic cocaine abuse and a bacterial infection. The patient presented with sudden vision loss, fixed mydriasis, and optic disc swelling. Despite steroids and antibiotics therapy, the patient developed peripheral ulcerative keratitis (PUK) following an upper respiratory bacterial infection.