This is for you smarties out there!

Case history:  A 44-year-old man with bilateral eyelid swelling  (Allergy Asthma Proc 33:205-11, 2012)

  • Swollen eyelids are commonly ascribed to “allergies” 

    What is this?
  • 4 month history of eyelid swelling (bilateral)
  • No ocular pain, visual disturbance, erythema, increased lacrimation, or itching–unusual for allergy!
  • Denies any trauma, foreign body, smoke exposures, facial swelling, throat involvement, or urticaria
  • Meds: amlodipine, rosuvastatin, mometasone nasal spray, fluticasone/salmeterol inhaler, montelukast (none should cause eyelid swelling)

What’s your differential diagnosis?

  • Angioedema–not likely without family history, normal complement levels, no recent medication alterations or ACE inhibitors. 
  • Skin testing was all negative
  • Thyroid function was normal
  • No physical exam findings of eczema, contact dermatitis, or blepharitis.
  • No temporal arteritis based on normal lab findings
  • And the list goes on….it’s all negative.

Bring in the biopsy:

  • Lymphoid hyperplasia with extensive acinar atrophy and mild fibrosis
  • Absence of ocular adnexa lymphoma or orbital parasitosis

After the biopsy revealed lymphoid hyperplasia, the patient had a baseline metastatic evaluation.  Immunostaining of the biopsy specimen revealed > 30% IgG4+ plasma cells. 

Final diagnosis:  IgG4-related dacryoadenitis.  Treatment at this time is wait & see.  Undergo a repeat metastatic survey and MRI of orbits in 6 months.  Wow–hope I never have to make that diagnosis!

Wikipedia to the rescue

The treatment of dacryoadenitis varies with onset and etiology.

  • Acute dacryoadenitis

    • Viral (most common) – Self-limiting, supportive measures (eg, warm compresses, oral nonsteroidal anti-inflammatories)
    • Bacterial – Initiate with first-generation cephalosporins (eg, Keflex 500 mg qid) until culture results are obtained.
    • Protozoan or fungal related – Treat the underlying infection accordingly with specific antiamoebic or antifungal agents.
    • Inflammatory (noninfectious) – Investigate for systemic etiology, and treat accordingly.
  • Chronic dacryoadenitis

    • In most cases, treat the underlying systemic condition.
    • If the enlargement does not subside after 2 weeks, consider lacrimal gland biopsy.
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