Unusual cause of saddle nose.

Starobinska E, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-221004 Description A 53-year-old female presented with a 2-week history of shortness of breath, cough and fever. Over the past 6 months, she reported painful tongue ulcers and pain in her nose, accompanied with nasal crusting and yellowish discharge. She had a history of pulmonary coccidioidomycosis, diagnosed 10 years ago, and she was treated with antifungal regimen. Physical examination revealed rhonchi bilaterally, multiple shallow ulcerative lesions on her tongue and a saddle nose deformity (figure 1A). CT of the chest demonstrated extensive ground-glass opacities with areas of nodular consolidation. Given her symptoms and history of coccidioidomycosis, nasal cavity biopsy was performed that revealed focal ulceration, non-specific inflammation with many cocci spherules, confirmed by Grocott’s methenamine silver stain (figure 1B). Cultures from the lesions and the sputum grew Coccidioides immitis. Treatment with fluconazole 400 mg daily was initiated, and after several days her symptoms improved. C. immitis is a pathogenic dimorphic fungus responsible for causing coccidioidomycosis, an infection that commonly affects the lungs and less often the skin. The clinical spectrum of the cutaneous lesions varies from papules, nodules, gummas, acneiform pustular lesions and abscesses. Our patient presented with disseminated coccidioidomycosis with pulmonary and skin involvement that caused chronic nasal cartilage inflammation, which we believe to be the first case report of saddle nose due to coccidioidomycosis. The most common cause for saddle nose is trauma, but the deformity can also be a feature of granulomatosis with polyangiitis, relapsing polychondritis, intranasal cocaine use, malignancies, syphilis, Crohn’s disease and lepromatous leprosy.