Methylphenidate abuse

Abstract

Midline destructive lesions, bone destruction and necrosis: case report A 46-year-old woman developed midline destructive lesions of the sinonasal tract, bone destruction and necrosis following methylphenidate abuse. The woman presented to a hospital in Israel with acute left eye proptosis and ophthalmoplegia, which occurred suddenly after blowing her nose earlier that day. Her medical history included hyperlipidaemia, diabetes, attention-deficit/hyperactivity disorder (ADHD), and depression. Clinical examination showed the uncorrected Snellen visual acuity was 6/6 in the right eye and 6/15 in the left eye. Examination of the left eye showed exotropia, proptosis, hypotropia, and full ophthalmoplegia. The left eyelids were found to be oedematous, the conjunctiva chemotic with air bubbles were seen beneath. Relative afferent pupillary defect was found positive in the left eye and intraocular pressure was found 22mm Hg. Examinations of the right eye yielded no notable findings. Nasal endoscopy showed severe anatomical distortion, mucosal necrosis, near total septal perforation, necrosis of inferior, middle and superior turbinate bilaterally, as well as ulcerations and crusting of the nasal cavity. She denied any previous surgery or nose picking. Nasal pyramid was without deformity and neither saddle nose nor loss of nasal projection was observed. Oral cavity examination showed continuous hard palate without defects and without oronasal fistula. Otoscopy revealed bilateral otitis media with effusion. Pure-tone audiometry showed bilateral conductive hearing loss. An urgent nasal biopsy was performed to examine the possibility of fulminant invasive rhino-orbital fungal disease, but no fungi were found. An urgent CT scan showed destruction of the nasal septum, inferior and middle nasal conchae, ethmoid sinuses, medial walls of the maxillary sinuses and lamina papyracea without palatine bone destruction. The skull base was found intact. The orbital CT scan revealed numerous intraorbital, intraconal, and periorbital air bubbles and dehiscence of the lamina papyracea. Those findings indicated an abnormal connection between the orbit and the nasal cavity, and was thought to be a consequence of mechanical force of air during nose blowing. Laboratory results showed the followings: leucocytosis 15.11 K/μL (15 110/μL), thrombocytosis 498 K/μL (4 98 000/μL), Hb 9.6 g/dL, glucose 211 mg/dL, and CRP 9.1 mg/dL. She was found negative for perinuclear anti-neutrophil cytoplasmic autoantibodies and cytoplasmic anti-neutrophil cytoplasmic autoantibodies, as well as for anti-proteinase-3 and anti-myeloperoxidase. The treponema pallidum particle agglutination assay and angiotensin converting enzyme were found within the normal limits. The woman received empiric treatment with amoxicillin/clavulanic-acid [amoxicillin-clavulanic acid], and tobramycin for her left eye. Three fragments of nasal mucosa were submitted for pathological examination. Abundant acute inflammatory infiltrates, as well as chronic inflammatory infiltrate were observed. One of the fragments showed necrosis; however, the necrosis did not showed the geographic pattern typical of granulomatosis with polyangiitis. No fibrinoid necrosis of vessels was observed. Numerous refractile, circular, and diamond-shaped crystals were seen. Following the pathology results, the anamnesis regarding drug abuse was enquired, and found that, she was inhaling intranasal (sniffing) methylphenidate [Ritalin; dosage not stated], regularly for over 1 year. A diagnosis of midline destructive lesions of the sinonasal tract, bone destruction and necrosis secondary to methylphenidate abuse was made [duration of treatment to reaction onsets not stated]. Three days later, her visual acuity returned to normal (6/6 in both eyes), and the proptosis, conjunctival chemosis, and ophthalmoplegia was resolved. Later, a comparison between pure methylphenidate with the foreign substance found in her nasal biopsy was performed, and under polarised light, a crystal structure that resembled the structure of the foreign substance from her nasal biopsy was observed.