[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [ENT](https://durgical.com/en/ent/) › [Nose and sinuses: approach to complaints](https://durgical.com/en/ent/areas/nose/) › Granulomatous diseases of the nose: leishmaniasis, leprosy, TB, syphilis, rhinoscleroma, rhinosporidiosis, GPA

# 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](https://durgical.com/en/anatomy/nasal-septum/) · [Nasal cavity](https://durgical.com/en/anatomy/nasal-cavity/) · [Nasal cartilages](https://durgical.com/en/anatomy/major-alar-cartilage/) · [Soft palate](https://durgical.com/en/anatomy/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](https://durgical.com/en/conditions/leishmaniasis/) | Endemic area, old skin ulcer | Anterior septal infiltration and perforation, swollen tip | Mucosal biopsy (Giemsa), PCR, indirect immunofluorescence |
| [Leprosy (lepromatous)](https://durgical.com/en/conditions/leprosy/) | Anaesthetic patches, thick nerves | Crusts, cartilaginous perforation, collapse | Slit-skin or nasal smear for acid-fast bacilli, biopsy |
| [Tuberculosis](https://durgical.com/en/conditions/tuberculosis/) | Pulmonary TB, contacts, HIV | Septal ulcer; apple-jelly nodules on the skin | Biopsy with culture and molecular test; chest X-ray |
| [Syphilis](https://durgical.com/en/conditions/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](https://durgical.com/en/conditions/paracoccidioidomycosis/) | Rural Colombia, coffee farming, smoking | Mulberry-like ulcers of mouth and nose | Smear or biopsy for multiple-budding yeast |
| [Granulomatosis with polyangiitis](https://durgical.com/en/conditions/granulomatosis-with-polyangiitis/) | Lungs, kidneys, eyes, ears | Crusts, bloody discharge, saddle nose | PR3-ANCA, urinalysis, creatinine, biopsy |
| [Sarcoidosis](https://durgical.com/en/conditions/sarcoidosis/) | Dry cough, lupus pernio, uveitis | Granular, crusted mucosa | Biopsy: non-caseating granulomas; chest X-ray |
| [NK/T-cell lymphoma or cocaine](https://durgical.com/en/conditions/non-hodgkin-lymphoma/) | 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)](https://durgical.app/estudiar/?add=/en/ent/granulomatous-diseases-of-the-nose-leishmaniasis-leprosy-tb-syphilis-rhinosclero/)

## Elsewhere in DurgiPedia

- [Granulomatous inflammation: caseating vs non-caseating, the causes to know](https://durgical.com/en/general-pathology/granulomatous-inflammation-caseating-vs-non-caseating-the-causes-to-know/)
- [Granulomatous inflammation](https://durgical.com/en/immunology/granulomatous-inflammation/)
- [The systematic oral exam: outside in](https://durgical.com/en/dentistry/the-systematic-oral-exam-outside-in/)
- [Systemic infections in the eye: syphilis, TB, toxoplasma](https://durgical.com/en/ophthalmology/systemic-infections-in-the-eye-syphilis-tb-toxoplasma/)

## Connections

## See it in 3D 4

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

- [Nasal septum](https://durgical.com/en/anatomy/nasal-septum/)
- [Nasal cavity](https://durgical.com/en/anatomy/nasal-cavity/)
- [Nasal cartilages](https://durgical.com/en/anatomy/major-alar-cartilage/)
- [Soft palate](https://durgical.com/en/anatomy/soft-palate/)

## Related 5

- [Approach to nasal blockage](https://durgical.com/en/ent/approach-to-nasal-blockage/)
- [Nasal exam: external nose, anterior rhinoscopy and nasal endoscopy](https://durgical.com/en/ent/nasal-exam-external-nose-anterior-rhinoscopy-and-nasal-endoscopy/)
- [Approach to nosebleed](https://durgical.com/en/ent/approach-to-nosebleed/)
- [Other nasal problems: rhinolith, nasal myiasis, synechiae, antrochoanal polyp and CSF leak](https://durgical.com/en/ent/other-nasal-problems-rhinolith-nasal-myiasis-synechiae-antrochoanal-polyp-and-cs/)
- [HIV and ENT: what to look for in the ear, nose, mouth and neck](https://durgical.com/en/ent/hiv-and-ent-what-to-look-for-in-the-ear-nose-mouth-and-neck/)

## Related conditions 12

- [Leishmaniasis](https://durgical.com/en/conditions/leishmaniasis/)
- [Leprosy (Hansen disease)](https://durgical.com/en/conditions/leprosy/)
- [Tuberculosis](https://durgical.com/en/conditions/tuberculosis/)
- [Syphilis](https://durgical.com/en/conditions/syphilis/)
- [Granulomatosis with polyangiitis](https://durgical.com/en/conditions/granulomatosis-with-polyangiitis/)
- [Sarcoidosis](https://durgical.com/en/conditions/sarcoidosis/)
- [Fungal sinusitis (invasive and noninvasive)](https://durgical.com/en/conditions/fungal-sinusitis/)
- [Paracoccidioidomycosis](https://durgical.com/en/conditions/paracoccidioidomycosis/)
- [Histoplasmosis](https://durgical.com/en/conditions/histoplasmosis/)
- [Nasal septal perforation](https://durgical.com/en/conditions/nasal-septal-perforation/)
- [Non-Hodgkin lymphoma](https://durgical.com/en/conditions/non-hodgkin-lymphoma/)
- [Cocaine and sympathomimetic toxicity](https://durgical.com/en/conditions/cocaine-and-sympathomimetic-toxicity/)

## Microorganisms 10

- [Leishmania (Viannia) panamensis, L. braziliensis and L. guyanensis](https://durgical.com/en/microbiology/leishmania-panamensis-l-braziliensis-and-l-guyanensis/)
- [Lutzomyia](https://durgical.com/en/microbiology/lutzomyia/)
- [Mycobacterium leprae](https://durgical.com/en/microbiology/mycobacterium-leprae/)
- [Mycobacterium tuberculosis](https://durgical.com/en/microbiology/mycobacterium-tuberculosis/)
- [Treponema pallidum](https://durgical.com/en/microbiology/treponema-pallidum/)
- [Klebsiella pneumoniae](https://durgical.com/en/microbiology/klebsiella-pneumoniae/)
- [Paracoccidioides brasiliensis](https://durgical.com/en/microbiology/paracoccidioides-brasiliensis/)
- [Histoplasma capsulatum](https://durgical.com/en/microbiology/histoplasma-capsulatum/)
- [Mucorales (Rhizopus, Mucor)](https://durgical.com/en/microbiology/mucorales/)
- [Epstein–Barr virus](https://durgical.com/en/microbiology/epstein-barr-virus/)

## In Pharmacology 12

- [Meglumine antimoniate](https://durgical.com/en/pharmacology/meglumine-antimoniate/)
- [Amphotericin B](https://durgical.com/en/pharmacology/amphotericin-b/)
- [Pentamidine](https://durgical.com/en/pharmacology/pentamidine/)
- [Miltefosine](https://durgical.com/en/pharmacology/miltefosine/)
- [Rifampicin](https://durgical.com/en/pharmacology/rifampicin/)
- [Dapsone](https://durgical.com/en/pharmacology/dapsone/)
- [Isoniazid](https://durgical.com/en/pharmacology/isoniazid/)
- [Benzathine benzylpenicillin](https://durgical.com/en/pharmacology/benzathine-benzylpenicillin/)
- [Ciprofloxacin](https://durgical.com/en/pharmacology/ciprofloxacin/)
- [Corticosteroids (glucocorticoids)](https://durgical.com/en/pharmacology/classes/corticosteroids/)
- [Rituximab](https://durgical.com/en/pharmacology/rituximab/)
- [Cyclophosphamide](https://durgical.com/en/pharmacology/cyclophosphamide/)

[← All of ENT](https://durgical.com/en/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)](https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/VS/PP/PAI/Lineamientos-leishmaniasis.pdf) (Ministerio de Salud y Protección Social de Colombia, 2023); [Leishmaniasis](https://www.ncbi.nlm.nih.gov/books/NBK531456/) (StatPearls Publishing (NCBI Bookshelf), 2026); [Leprosy](https://www.who.int/news-room/fact-sheets/detail/leprosy) (World Health Organization, 2026); [Leprosy](https://www.ncbi.nlm.nih.gov/books/NBK559307/) (StatPearls Publishing (NCBI Bookshelf), 2026); [Syphilis](https://www.ncbi.nlm.nih.gov/books/NBK534780/) (StatPearls Publishing (NCBI Bookshelf), 2024); [Granulomatosis With Polyangiitis](https://www.ncbi.nlm.nih.gov/books/NBK557827/) (StatPearls Publishing (NCBI Bookshelf), 2024); [Septal Perforation](https://www.ncbi.nlm.nih.gov/books/NBK537208/) (StatPearls Publishing (NCBI Bookshelf), 2023); [Rhinosporidium seeberi: A Human Pathogen from a Novel Group of Aquatic Protistan Parasites (Emerging Infectious Diseases)](https://wwwnc.cdc.gov/eid/article/6/3/00-0307_article) (Centers for Disease Control and Prevention (CDC), 2000).

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Representative model, for educational purposes only.

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Source: https://durgical.com/en/ent/granulomatous-diseases-of-the-nose-leishmaniasis-leprosy-tb-syphilis-rhinosclero/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/ent/granulomatous-diseases-of-the-nose-leishmaniasis-leprosy-tb-syphilis-rhinosclero/