Q:

17 y/o AA female with periorbital swelling. It is bilateral and I'm not convinced this is angioedema. Looks like very prominent "shiners". She has AR, but few symptoms. No swelling of other body parts, no abdominal symptoms. Never obstruction of her vision because of eyelid edema. I planned on checking kidney function, C4 levels--anything else you would do? How would you treat this problem? She hasn't responded to antihistamines. Thanks.

A:

Thank you for your recent inquiry.

From your description I would agree with you that it is unlikely that your patient is suffering from angioedema. Firstly, angioedema of the periorbital region is, in the vast majority of instances, unilateral. It also sounds (although I cannot be sure) from your description that the episodes you are describing are not acute, episodic, and rapidly resolving. Angioedema episodes of the periorbital region usually do not last more than 24 to 48 hours, and then resolve completely. They are explosive in onset and do not, in the vast majority of instances, produce a chronic puffiness of the lids.

The differential diagnosis in bilateral periorbital edema is quite extensive, and when it involves only the lower lids, in a patient with rhinitis, it can certainly be due to the rhinitis itself. This is irregardless of whether it is allergic or nonallergic in nature. This chronic lower lid puffiness with “shiners” is thought to be due to obstruction of venous blood flow secondary to nasal congestion regardless of cause.

Of course there are other causes of bilateral periorbital edema, but most of these involve the upper and lower lid. So, a location around the lower lid only strongly points to the type of periorbital puffiness that is associated with rhinitis.

In some instances this type of puffiness can be congenital. In these cases there is very little that one can do from a medical standpoint.

Of course, there are other causes of periorbital edema such as thyroid and kidney disease, and other conditions which are far more esoteric. From your description, however, none of these seem to apply to your patient.

From your description, I do not think that I would pursue a workup for angioedema of any sort because more than likely your workup would be negative. Even in clear-cut cases of angioedema, as you know, the vast majority of patients suffer from idiopathic angioedema. With the history you present, I do not even see a strong reason to order a C4 level.

If you have a clinical suspicion of any other medical cause such as thyroid disease, I would go ahead and evaluate your patient in that regard. A standard lengthy list of conditions associated with periorbital angioedema can be obtained via the Internet simply by Googling “differential diagnosis of periorbital angioedema.” You could then pursue any medical test you feel indicated based upon this differential and your conclusions obtained by your history and physical.

You might, however, simply empirically try and treat her rhinitis with a topical nasal steroid and see if this offered improvement. You could consider doing this before initiating a workup if you don’t find any symptoms that would suggest the rarer causes of this condition such as systemic lupus and dermatomyositis.

In summary, my guess is that she does not have angioedema. My suspicion is, especially if the puffiness involves only the lower lids, that she might have swelling due to her rhinitis, but if there is any clinical indication, you could evaluate her further, ordering tests to which you are guided by her history and physical findings and the differential diagnosis of bilateral periorbital edema which can be found readily online.

I agree with you that her symptoms are not consistent with angioedema, and would personally not pursue a workup of angioedema at this time.

Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology