gms | German Medical Science

Most malignant lesions of the outer nose are of epithelial origin. Basal cell carcinoma and spinocellular carcinoma are the most common entities. Benign or precancerous lesions are important differential diagnoses. Other tumor entities such as melanoma, sarcoma or lymphoma are comparatively rare.

Case: A 54-year-old male patient suffered from a destructive infiltrating tumor of the right nasal entrance. On first presentation we found a necrosis of the columella with an accompanying inflammation of the nasal and paranasal skin. Under the suspicion of a necrotizing inflammation affected parts of the anterior septum were removed combined with a local and systemic antibiotic treatment. Histopathology confirmed a necrotizing inflammation involving vessels comparable to a late stage of Wegner’s granulomatosis. However ANCA and ANA were negative. There was no evidence for abdominal, pulmonary or cerebral involvement.

Suspecting Wegner’s disease with false negative ANCA and local manifestation the patient was treated immunosuppressive with cyclophoshamid, later with azathioprine and prednisolon.

After a brief period of improvement disease progressed again resulting in an extensive septal perforation. A second histopathology specimen was taken and revealed a cutaneous large B-cell lymphoma. Treatment was changed to cyclophoshamide, doxorubicine, vincristine, rituximab as well as prednisolon.

Concurrent heavy inflammation can be misleading a correct diagnosis clinically as well as histopathologically. Only repeated biopsy after treatment of inflammation was able to find the real cause in our case. If there are discrepancies between clinical, histological and serological findings one should think of rare differential diagnosis too.