Objectives
Cocaine and cocaine mixed with levamisole are increasingly used in the UK and result in significant direct nasal damage in addition to promoting vasculitis. Our aims were as follows: (1) to identify the main symptoms and presentation of cocaine-induced vasculitis; (2) to provide evidence regarding the best practice for the investigation and diagnosis of cocaine-induced vasculitis; and (3) to analyse the clinical outcomes of patients in order to understand the optimal management for the condition.
Methods
We performed a retrospective case series analysis of patients presenting with cocaine-induced midline destructive lesions or vasculitis compatible with granulomatosis with polyangiitis (GPA) from two large tertiary vasculitis clinics between 2016 and 2021.
Results
Forty-two patients (29 Birmingham, 13 London) with cocaine-induced midline lesions or systemic disease were identified. The median age was 41 years (range 23–66 years). Current cocaine use was common, and 20 of 23 samples provided were positive when routine urine toxicology was performed; 9 patients who denied ever using cocaine were identified as using cocaine based on urine toxicology analysis, and 11 who stated they were ex-users still tested positive. There was a high incidence of septal perforation (75%) and oronasal fistula (15%). Systemic manifestations were less common (27%), and only one patient had acute kidney injury. Fifty-six per cent of our patients were PR3-ANCA positive, with none testing positive for MPO-ANCA. Symptom remission required cocaine discontinuation even when immunosuppression was administered.
Conclusion
Patients with destructive nasal lesions, especially young patients, should have urine toxicology performed for cocaine before diagnosing GPA and considering immunosuppressive therapy. The ANCA pattern is not specific for cocaine-induced midline destructive lesions. Treatment should be focused on cocaine cessation and conservative management in the first instance in the absence of organ-threatening disease.
This paper analyses “the force of things” (Bennett 2010, 1) in Aeschylus’ Niobe, in particular the function of two material props (in a broader sense): the tomb of Niobe’s children and her mourning veil. These will be examined through both textual evidence and visual representations of the myth. Aristoph. Frogs 911-20 (test. 120 R) describes Niobe as seated, veiled, and silent for half of Aeschylus’ play (cf. also Vit. Aeschyl. 5-6 = test. 1.19-23 R). With such a static plot, material props are crucial; from a cognitive, physical, and psychological point of view they deeply affect the main character, as well as the other characters (including the chorus) and the spectators, who experience Niobe’s feelings through her contact with the material medium. The physical and psychological relationship between Niobe and the tomb affects her communication with the other characters, her own perception of reality and her capability to act. The grave locks Niobe into her grief, preventing her from moving forward – and physically away from it – and even from communicating with the outer world. The mourning veil is the material expression of this interrupted relationship. It acts as a material barrier, preventing communication between Niobe and the other characters: it weakens her physical and cognitive perception of the world, as well as her capacity to act, ‘sealing’ the character in her silence. Moreover, the veil separates Niobe from the world of the living, entrapping her in an exclusive relationship with her dead children.
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