Rheumatology · Medical Literature
Case 22-2026: A 37-Year-Old Woman with Persistent Nasal Ulceration
Abstract
New England Journal of Medicine, Volume 395, Issue 5, Page 493-501, July 30, 2026.
Clinical relevance
In a 37-year-old woman with a 17-year history of unilateral nasal scabbing, bleeding, and endoscopically confirmed multifocal crusting and ulceration, what is the unifying diagnosis? __SNAPSHOT__ {"studyDesign":"Clinicopathological Conference (CPC) — Case Record of the Massachusetts General Hospital; single case report with structured diagnostic discussion","setting":"Mass Eye and Ear / Massachusetts General Hospital / Brigham and Women's Hospital, Boston, MA, USA; presented at Mass Eye and Ear Rhinology Grand Rounds","sampleSize":"n=1 (single patient case report)","population":"37-year-old woman with a 17-year history of unilateral nasal scabbing and epistaxis; endoscopy demonstrating marked, multifocal nasal crusting and ulceration","intervention":"Diagnostic evaluation including nasal endoscopy, histopathological assessment (Department of Pathology, MGH), and multispecialty clinical correlation (Otolaryngology–Head and Neck Surgery, Internal Medicine/Rheumatology, Pathology)","comparator":"Not applicable — single-arm diagnostic case report","primaryOutcome":"Establishment of a definitive clinicopathological diagnosis for persistent, unilateral nasal ulceration of 17 years duration","followUp":"Not reported","fundingSource":"Not reported; disclosure forms available at NEJM.org per publisher notation"}
Key findings
This is a clinicopathological conference case report; no quantitative outcomes, effect sizes, p-values, confidence intervals, or NNT/NNH are applicable or reported. The case centers on a 37-year-old woman with a 17-year history of unilateral nasal scabbing and bleeding in whom nasal endoscopy revealed marked, multifocal crusting and ulceration. A definitive diagnosis was reached through multispecialty collaboration involving otolaryngology (Stacey T. Gray, MD), internal medicine (Carolina D. Geadas, MD, Brigham and Women's Hospital), and pathology (Peter M. Sadow, MD, PhD, MGH). The full diagnostic reasoning, differential diagnosis discussion, and pathological findings are contained within the complete case record (NEJM Vol. 395, No. 5, pp. 493–501); the specific final diagnosis and all supporting data are not available from the abstract alone and are behind a paywall. No adverse events or treatment outcomes are reportable from the abstract.
Practice implications
IMPORTANT LIMITATION: Only the abstract/introductory paragraph of this case record is publicly available; the full clinical discussion, differential diagnosis reasoning, pathological findings, and final diagnosis are accessible only to NEJM subscribers. Conclusions herein are therefore necessarily incomplete and must not be used as the basis for clinical decision-making. What the case establishes (from available data): This CPC illustrates the diagnostic challenge of chronic, unilateral nasal ulceration persisting for nearly two decades in a young woman — a presentation that demands systematic exclusion of a broad differential including but not limited to: granulomatous diseases (granulomatosis with polyangiitis [GPA/Wegener's], sarcoidosis, eosinophilic granulomatosis with polyangiitis), chronic infections (rhinoscleroma, leishmaniasis, fungal infection, tuberculosis, syphilis), cocaine-induced midline destructive lesion (CIMDL), neoplastic processes (NK/T-cell lymphoma, squamous cell carcinoma), and autoimmune mucosal diseases. The chronicity (17 years without systemic progression implied by survival to referral) may favor a more indolent or localized etiology over aggressive vasculitis or malignancy, though this inference should not substitute for full case review. What was NOT established from the abstract: the specific diagnosis, the workup sequence and results, serologic and microbiologic data, imaging findings, histopathological features, and any treatment rendered or response observed. Applicability: findings and diagnostic reasoning apply to the individual patient described; generalizability to other patients cannot be assessed without full case access. __LIMITATIONS__ 1. Single case report format: no control group, no statistical inference, no generalizability in the conventional sense. 2. Only the abstract is publicly available; the differential diagnosis discussion, diagnostic reasoning, pathological findings, and final diagnosis cannot be independently verified or fully summarized. 3. Inherent selection bias: CPC cases are selected for educational complexity and may not represent the typical presentation of the eventual diagnosis. 4. No quantitative outcomes, treatment response data, or follow-up duration are reported in the abstract. 5. Single-institution, tertiary academic center case (Mass Eye and Ear / MGH / BWH) limits generalizability to community practice settings. 6. Funding source and potential conflicts of interest are not disclosed in the abstract; disclosure forms are available only with the full text. __BOTTOM_LINE_CATEGORY__ not_ready_for_clinical_application __BOTTOM_LINE__ This NEJM Case Record presents a diagnostically challenging case of persistent unilateral nasal ulceration in a 37-year-old woman with a 17-year symptom history, requiring multispecialty evaluation across otolaryngology, internal medicine, and pathology to reach a definitive diagnosis. Clinicians encountering chronic nasal ulceration of this duration should maintain a broad differential encompassing granulomatous vasculitis, chronic infection, toxin-mediated destruction, and neoplasia, guided by endoscopic findings, serologic workup, and tissue biopsy. Full access to the complete case record (NEJM 2026;395:493–501) is necessary to review the diagnostic reasoning, histopathological findings, and final diagnosis.