Intranasal cocaine-induced midline destructive lesions are described to be difficult to distinguish from what small vessel vasculitis?
Granulomatosis with polyangiitis (GPA) (formerly Wegener’s granulomatosis). Both conditions exhibit similar features when limited to destructive nasal lesions, and have positive anti-neutrophil cytoplasmic antibodies . However, human neutrophil elastase is a diagnostic marker for cocaine-induced midline destructive lesions that is almost never detectable in GPA. 
1)Alba Escolà-Rodríguez, Marina Parra-Robert, Daniel Carrasco-Gómez, Teresa Escartín-Díez & Aleix B. Fabregat-Bolufer (2023) Diagnosis of cocaine-induced midline destructive lesions, Clinical Toxicology, DOI: 10.1080/15563650.2023.2259090 2) Rachapalli SM, Kiely PD. Cocaine-induced midline destructive lesions mimicking ENT-limited Wegener’s granulomatosis. Scand J Rheumatol. 2008;37(6):477–480. doi: 10.1080/03009740802 192043
Contributed by: Catherine Dong The Medical Toxicology Fellowship, Virginia Commonwealth University, Richmond, VA