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”
- 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!
The treatment of dacryoadenitis varies with onset and etiology.
- 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.
- In most cases, treat the underlying systemic condition.
- If the enlargement does not subside after 2 weeks, consider lacrimal gland biopsy.