Presenter: D. Ryan Skinner DO, Gina Caputo DO

Dermatology Program: Lewis Gale Hospital Montgomery

Program Director: Dr. Daniel Hurd

Submitted on: Nov 17, 2014

CHIEF COMPLAINT:  Bilateral swelling to the face

CLINICAL HISTORY: A 29-year-old female with a history of type 2 insulin-dependent diabetes mellitus presented to the clinic with bilateral facial swelling that had been present for approximately a year and a half. She has had an extensive workup and been seen by her PCP, as well as allergy, ophthalmology, and rheumatology with no clear etiology being found. Her facial edema is generally always present, but waxes and wanes in its severity. Previous treatment includes doxycycline 100mg twice a day. 

PHYSICAL EXAM:
Symmetric, non-pitting, non-painful firm edema over the glabellar region, midface, nasal saddle, and infraorbital regions as well as some mild background erythema. Multiple acne nodules on bilateral cheeks as well as evidence of scarring from acne.

LABORATORY TESTS:

The patient has had an extensive workup including C1 esterase, C1q, C2, C4, head, and neck CT. She has also had an autoimmune workup including ANA, ds-DNA, Anti-Jo, TSH, thyroglobulin, celiac panel, P-ANCA, P-ANCA, scl-70, SS-A, SS-B, aldolase, and CK. All negative. She has undergone allergy testing with negative prick testing and positive patch testing to the glue used in textiles. Also, CBC, CMP, ESR, CRP, and SPEP, UPEP were all within normal limits. In addition to this, ASO, HIV, and trichinella testing were also all within normal limits.

DERMATOHISTOPATHOLOGY:

Punch biopsy from left lower eyelid: Dermal edema and perivascular chronic inflammation.

DIFFERENTIAL DIAGNOSIS:

1.   Angioedema
2.   Erysipelas
3.   Allergic/irritant contact dermatitis
4.   Melkerson-Rosenthol syndrome
5.   Solid facial edema (Morbihan’s syndrome)