Q:

12/11/2013
Three year-old patient has bilateral periorbital edema since the age of 8 months, it mainly obvious in the lower eyelids when she wakes up in the morning and gradually decreases through the day but does not disappear completely, otherwise she is fine with no edema else where. I did urine test for her looking for proteins but it was negative. Her mother and father have a history of atopy, allergic rhinitis and asthma. The child and father are G6PD.

A:

Thank you for your inquiry.

We recently dealt with a question regarding periorbital edema in an adult on our website. Since the differential diagnosis of periorbital edema was discussed in that entity, for your interest, I have copied it below. One of course needs to consider all of the entities mentioned in the differential diagnosis. However, because of several features you mentioned in your letter, it is highly likely that the child's periorbital edema is related to a benign cause, rhinitis. When a child has rhinitis, blood flow of the nose is obstructed, and edema often appears in both eyes. The features in your case that point toward that are:

1. Bilateral nature of the edema.

2. The fact that the lower lids are predominantly affected.

3. The fact that both parents have a history of atopic disease.

4. The symptoms are worse in the morning and resolve during the day.

5. She has no other symptoms.

In children, this type of periorbital edema has been referred to as "allergic shiners," but it is not really the allergy per se that produces it; it is swelling of the nasal tissue. This occurs in any form of rhinitis, be it allergic or nonallergic.

With these thoughts in mind, I would suggest that you consider a visit with an allergist in your geographical location for a nasal examination and possibly testing for allergies. If you are not aware of an allergist in your area, you can go to our "Find an Allergist-Immunologist" to locate one in your vicinity. Alternatively, to do a nasal examination, an otolaryngologist might be consulted. Finally, if you have not discussed the issue with the child's pediatrician, I would suggest you do so as well.

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

Question:
I have a very unusual case of eyelid swelling (upper and less lower), which lasts without ANY change for about 16 months! Patient is young female (24), there are absolutely no changes in the skin, no rush no erithema, and patient is otherwise in a very good health. The swelling is also present in the nose which is completely blocked, and there were episodes of tongue swelling which stopped after a while. The only therapy in which she ever reacted well was a short treatment with medrol orally, together with klaricid. All tests available to us were conducted, including renal, cardio vascular, thyroid, immune etc. please help!

Answer:
Thank you for your inquiry.

I am afraid I may not be able to be as helpful as I would hope to be. The reason for this is that the picture your patient presents is not one we would normally deal with in Allergy-Immunology. I can say that with confidence because the types of eyelid swelling that we would see would be due to contact dermatitis in which the skin would be involved, or angioedema in which the swelling would be evanescent. Also, I am not aware of any cause which would be associated with swelling of the tongue or nasal cavity. I am not sure in actuality that the swelling of the nasal cavity is related. It is possible that this is a separate phenomenon. Thus, the only thing I can tell you with confidence is that none of the normal investigative processes that an allergist would employ would be of help to you with this patient. Therefore all I can do is to point you to the classic differential diagnosis of periorbital edema.

The causes of chronic periorbital edema, considering the fact that you have ruled out thyroid disease and nephrotic syndrome, are somewhat limited in number. Some of these diagnoses are esoteric and probably do not fit your patient, but for the sake of completeness, I will list several for you:

1. Cavernous sinus thrombosis.

2. Dermatomyositis.

3. Superior vena cava obstruction.

4. ENT tumors.

5. Rarely patients with Melkersson-Rosenthal syndrome can have recurrent orofacial swelling. This would be consistent perhaps with the problem your patient has noted with the tongue.

6. Proptosis associated with pseudotumor of the orbit.

Any test that you might pursue would therefore be directed at investigating these diagnoses and might include a CT scan or MRI of the orbit, CT scan or MRI of the mediastinum, and a biopsy of the swollen tissue. Also you might consider, if you have not already done so, a consultation with an ophthalmologist, and if the skin itself is thickened, a dermatologist.

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