Granulomatous diseases of the nose: leishmaniasis, leprosy, TB, syphilis, rhinoscleroma, rhinosporidiosis, GPA

Topic

Crusting, bleeding and a nose that slowly destroys itself point to chronic infections, vasculitis, lymphoma or cocaine; a biopsy decides which.

Updated Nov 12, 2026

See it in 3D: Nasal septum · Nasal cavity · Nasal cartilages · Soft palate

Key points

Colombia: mucosal leishmaniasis (mostly Leishmania (Viannia) braziliensis) starts on the anterior nasal septum, usually within 2 years after the skin ulcer heals.
MinSalud: ask every patient with cutaneous leishmaniasis about nasal blockage, discharge or nosebleeds, and examine the nose.
Mucosal leishmaniasis is confirmed by mucosal biopsy (Giemsa), PCR or indirect immunofluorescence; first-line treatment is meglumine antimoniate, supervised.
Septal perforation of the cartilage: trauma, nose picking, cocaine, leishmaniasis, leprosy, TB, GPA; of the bony septum: classically tertiary syphilis.
GPA: crusting, bloody discharge, saddle nose and sinusitis with lung or kidney disease and PR3-ANCA (c-ANCA); it needs urgent immunosuppression.
Rhinoscleroma (Klebsiella rhinoscleromatis): Mikulicz cells on biopsy; rhinosporidiosis: a strawberry-like bleeding polyp with sporangia.

What it is

Several chronic diseases form granulomas in the nasal mucosa and slowly destroy the septum, the palate or the whole midface. They share the same picture: blockage, crusts, foul or bloody discharge, a septal perforation and, late, a collapsed (saddle) nose. In Colombia the first one to think of is mucosal leishmaniasis, which can appear years after a skin ulcer has healed; leprosy, tuberculosis, syphilis and the deep mycoses (paracoccidioidomycosis, histoplasmosis) are the other infections. Non-infectious mimics are granulomatosis with polyangiitis, sarcoidosis, extranodal NK/T-cell lymphoma and cocaine use. The history (endemic area, old scars, drugs, sexual risk) narrows the list, but the answer comes from a deep biopsy with cultures and special stains. This page is the approach; each disease has its condition page.

Key facts

Where has the patient lived, worked or travelled (forest, rural work, military service)?
Any old skin ulcer or scar, especially one treated for leishmaniasis?
Numb skin patches or thickened nerves (leprosy)? Cough, fever, night sweats (TB)?
Cocaine use, nasal sprays or nasal surgery?
Sexual risk, HIV status, mother's syphilis history?
Haemoptysis, blood in the urine, joint pain, red eyes (GPA) or dry cough and skin plaques (sarcoidosis)?

Structure

Protozoa: mucosal leishmaniasis (Viannia subgenus; L. braziliensis, also L. panamensis and L. guyanensis).
Mycobacteria: leprosy (lepromatous form, nasal mucosa heavily loaded with bacilli) and tuberculosis (septal ulcer, lupus vulgaris of the nasal skin).
Spirochaete: syphilis (congenital snuffles in infants; tertiary gumma destroying bone, septum and palate).
Bacteria: rhinoscleroma (Klebsiella pneumoniae subspecies rhinoscleromatis).
Other organisms: rhinosporidiosis (Rhinosporidium seeberi, an aquatic protist), paracoccidioidomycosis, histoplasmosis and chronic invasive fungal sinusitis.
Non-infectious: granulomatosis with polyangiitis, sarcoidosis, extranodal NK/T-cell lymphoma nasal type (EBV) and cocaine-induced midline destruction.

Granulomatous and destructive nasal diseases: how to tell them apart

Disease	Clue in the history	Nose finding	Key test
Mucosal leishmaniasis	Endemic area, old skin ulcer	Anterior septal infiltration and perforation, swollen tip	Mucosal biopsy (Giemsa), PCR, indirect immunofluorescence
Leprosy (lepromatous)	Anaesthetic patches, thick nerves	Crusts, cartilaginous perforation, collapse	Slit-skin or nasal smear for acid-fast bacilli, biopsy
Tuberculosis	Pulmonary TB, contacts, HIV	Septal ulcer; apple-jelly nodules on the skin	Biopsy with culture and molecular test; chest X-ray
Syphilis	Sexual risk; congenital in infants	Bony septal and palatal perforation, saddle nose	Nontreponemal and treponemal serology
Rhinoscleroma	Endemic area, crowding, poverty	Hard nodules, scarring narrowing	Biopsy: Mikulicz cells, Russell bodies; culture
Rhinosporidiosis	Bathing in ponds or rivers	Strawberry-like bleeding polyp	Histology: sporangia with endospores
Paracoccidioidomycosis	Rural Colombia, coffee farming, smoking	Mulberry-like ulcers of mouth and nose	Smear or biopsy for multiple-budding yeast
Granulomatosis with polyangiitis	Lungs, kidneys, eyes, ears	Crusts, bloody discharge, saddle nose	PR3-ANCA, urinalysis, creatinine, biopsy
Sarcoidosis	Dry cough, lupus pernio, uveitis	Granular, crusted mucosa	Biopsy: non-caseating granulomas; chest X-ray
NK/T-cell lymphoma or cocaine	Fever and weight loss, or drug use	Midline necrosis and perforation	Deep biopsy with EBV studies; history and toxicology

In clinical practice

Mucosal leishmaniasis: blockage, itching or pain, blood-stained crusts and discharge; the tip and alae swell; the cartilaginous septum perforates; late, the palate, pharynx, larynx and upper lip are destroyed and the tip droops («tapir nose»).
Leprosy: nasal stuffiness, crusts and nosebleeds may be the first symptoms; the cartilaginous septum perforates and the nose collapses; look for anaesthetic skin patches and thick nerves.
Syphilis: a tertiary gumma destroys the bony septum and hard palate (saddle nose, palatal perforation); in congenital syphilis, persistent snuffles in the infant and saddle nose later.
Rhinoscleroma passes from a catarrhal stage to a granulomatous (nodular) stage and then to scarring that narrows the nose, nasopharynx, larynx or trachea.
Rhinosporidiosis: one-sided friable, red, mulberry-like polyp that bleeds on touch, after bathing in ponds or rivers; endemic in South India and Sri Lanka, sporadic in the Americas.
Red flags: stridor or hoarseness (larynx), palatal perforation, rapidly spreading black or pale necrosis (invasive fungal disease), renal or lung involvement (GPA), fever and midline destruction (lymphoma).

Next step / Initial management

First workup: full nasal and oral exam (palate, gums, pharynx), skin scars and nerves, chest X-ray, full blood count, creatinine, urinalysis, ANCA, syphilis serology and an HIV test.
Suspected mucosal leishmaniasis: under the MinSalud guideline, refer to a specialist at second or third level for mucosal biopsy with Giemsa, indirect immunofluorescence and tissue PCR; if a skin lesion is also present, take the smear from the skin, not the mucosa. Notify SIVIGILA once confirmed.
Leishmaniasis treatment is supervised: first line meglumine antimoniate; alternatives amphotericin B, pentamidine or miltefosine; baseline liver enzymes, amylase and lipase, blood count, renal function and ECG when indicated, and follow-up for two years.
Other infections: leprosy with WHO multidrug therapy (rifampicin, dapsone, clofazimine; free of charge), TB with the standard regimen, syphilis with benzathine penicillin, rhinoscleroma with long courses of ciprofloxacin or a tetracycline plus debridement, rhinosporidiosis with surgical excision.
Do not give systemic corticosteroids before the biopsy: they can hide a lymphoma or worsen an infection.
Refer urgently (same day) for stridor, a palate or orbit being destroyed, black or pale necrosis in a diabetic or immunosuppressed patient, or GPA with kidney or lung involvement; every other destructive nasal lesion gets a priority ENT referral for deep biopsy.

Test yourself

Think of the answer, then tap the question to see it.

A Colombian soldier had an arm ulcer two years ago. He now has nasal blockage, bloody crusts, a swollen nasal tip and an anterior septal perforation. Most likely diagnosis?

Mucosal leishmaniasis, usually by Leishmania (Viannia) braziliensis; it starts on the anterior septum, often within 2 years after the skin lesion heals.

Which test confirms mucosal leishmaniasis in the MinSalud guideline, and what is the first-line drug?

Biopsy of the affected mucosa with Giemsa, supported by tissue PCR or indirect immunofluorescence; first line is meglumine antimoniate, given under supervision.

A perforation involves the bony septum and the hard palate, with a saddle nose. Which infection is classic?

Tertiary syphilis (gumma); most other causes perforate the anterior cartilaginous septum.

A biopsy of a nodular, scarring nasal lesion shows large foamy histiocytes (Mikulicz cells) and Russell bodies. What is the diagnosis?

Rhinoscleroma, caused by Klebsiella pneumoniae subspecies rhinoscleromatis; long antibiotic courses plus debridement.

A patient has nasal crusting, saddle nose, haemoptysis and haematuria. Which antibody do you order?

ANCA, looking for PR3-ANCA (c-ANCA) of granulomatosis with polyangiitis; also urinalysis, creatinine, chest imaging and urgent referral.

Add to my cards (5)

Elsewhere in DurgiPedia

Connections

See it in 3D4

The structures of Durgical's 3D anatomy where it is found.

Microorganisms10

In Pharmacology12

← All of ENT

Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.

Sources: Lineamientos de atención clínica integral para leishmaniasis en Colombia (versión 4) (Ministerio de Salud y Protección Social de Colombia, 2023); Leishmaniasis (StatPearls Publishing (NCBI Bookshelf), 2026); Leprosy (World Health Organization, 2026); Leprosy (StatPearls Publishing (NCBI Bookshelf), 2026); Syphilis (StatPearls Publishing (NCBI Bookshelf), 2024); Granulomatosis With Polyangiitis (StatPearls Publishing (NCBI Bookshelf), 2024); Septal Perforation (StatPearls Publishing (NCBI Bookshelf), 2023); Rhinosporidium seeberi: A Human Pathogen from a Novel Group of Aquatic Protistan Parasites (Emerging Infectious Diseases) (Centers for Disease Control and Prevention (CDC), 2000).

Spotted a mistake?We are always improving for the community. Tell us what is wrong and our team will review it.Report a mistake

Representative model, for educational purposes only.