Q:

12/8/2013
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!

A:

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