Nasal Septal perforation: Iatrogenic, Autoimmune or Infective? A diagnostic Challenge

Abstract

Introduction:
Nasal septal perforation is a rare but significant clinical condition that may present with symptoms such as nasal discharge, crusting, bleeding, and deformity. Its etiology can be diverse ranging from trauma and infection to autoimmune diseases. We report a diagnostically challenging case of nasal septal perforation following COVID-19-related hospitalization.

Case Report:

A 48-year-old female with chronic kidney disease, on regular dialysis, presented with foul-smelling nasal discharge, black crusts, and a saddle nose deformity one-year post-COVID-19 ICU admission involving nasal intubation. Initial examination revealed a large septal perforation with extensive crusting and greenish discharge. Preliminary diagnosis was atrophic rhinitis with secondary bacterial infection (E. coli), but symptoms persisted despite treatment. Subsequent biopsy revealed invasive fungal infection with Aspergillus fumigatus. Antifungal therapy with voriconazole was initiated, with initial clinical improvement. However, the patient was later lost to follow-up and subsequently reported deceased due to unknown complications.

Conclusion:
This case illustrates the diagnostic complexity of nasal septal perforation, especially in immunocompromised patients with multiple possible etiologies such as iatrogenic trauma, fungal infection, and vasculitis. A multidisciplinary diagnostic approach is essential for accurate diagnosis and effective management.