Alcohol-related massive eyelid swelling: case …

1 Arq Bras Oftalmol. 2007;70(1):169-71 Edema palpebral maci o relacionado ao uso de lcool: relato de caso1MD, PhD, Department of Internal Medicine from ArmedForces Hospital - HFA - Bras lia (DF) - Brazil; CatholicUniversity Medical Course - Bras lia (DF) - , Specialist from the Brazilian Society of Derma-tology - Bras lia (DF) - , Department of Internal Medicine from HFA - Bra-s lia (DF) - , Department of Internal Medicine from HFA - Bra-s lia (DF) - , Department of Internal Medicine from HFA - Bra-s lia (DF) - Student, Catholic University Medical Course- Bras lia (DF) - to correspondence: Vitorino Modesto dosSantos. SMPW - Quadra 14 - Conjunto 2 - Lote 7 - CasaA - Bras lia (DF) CEP 71745-140E-mail: para publica o em ltima vers o recebida em o em interests: The authors have no conflict ofinterest to discloseNota Editorial: Depois de conclu da a an lise doartigo sob sigilo editorial e com a anu ncia do rgio Felberg sobre a divulga o de seu nome comorevisor, agradecemos sua participa o neste Modesto dos Santos1 Taciana Arruda Modesto Sugai2 Fabiano Girade Corr a3 Elber Rocha Barbosa J nior4 Fluvia Manuela Canhete Siqueira5 Ant nio Victor Paes de Vasconcelos6 INTRODUCTIONM assive swelling of the eyelids is a rare condition that can cause severevisual impairment and has been associated with rosaceous lymphedema(1-2).

2 Causes of orofacial edema includes: angioedema; Ascher s syndrome;scleredema adultorum of Buschke; cardiac, endocrine, hepatic and renaldisease; Crohn s disease; drugs; infections; kwashiorkor; lymphatic sta-sis; Melkersson-Rosenthal syndrome; morbus morbihan; neoplasms; rosa-cea; sarcoidosis; storage disease; urticaria; and vena cava obstruction(1-8).About 90% of chronic alcoholics may show skin, hair, nail or oralchanges, some associated with malnutrition, poor hygiene, and following skin changes are common after a decade of heavy drinking:clubbing; eczema; erythema; flushing; gingivitis; glossitis; icterus; infec-tions; koilonychias; leukoplakia; lichenoid dermatitis; pellagra; porphyria;pruritus; psoriasis; purpura; rosacea; seborrheic dermatitis; telangiectasis;and tinea versicolor(9).Alcohol consumption constitutes a long-term relentless problem ofpublic health in the whole world; nevertheless, ethanol abuse has not beenpursued as it should be(10).

3 Moreover, among women and old-aged men, thecharacterization of Alcohol-related conditions is often more difficult thanamong young males(11). case REPORTA 43-year-old Brazilian nonatopic male came to the hospital complainingof a disfiguring symmetrical eyelid swelling , with impaired vision. He denieddrug use, but consumed alcohol (70-140 g/week) and tobacco for more thanten years. In the last 2 years, he presented episodic pruritic facial swelling ,more evident on the eyelids, with an ethanol dose-response effect follo-wing the spirit drinking binges. There was no either personal or familyhistory of allergy or antecedent of hypersensitivity diseases, and the pa-tient was not using any medicine. On physical examination, the disfiguringedema was restricted to the face, and the eyelids were the most affectedAlcohol- related massive eyelid swelling : case reportKeywords: Alcoholism/complications; Edema; Eyelids; Lymphedema; case reports [pu-blication type] Alcohol-related massive eyelid edema has been rarely reported.

4 Thedifferential diagnosis includes local and systemic conditions. Alcoholitself can be associated with dermatological hypersensitivity reactions,appearing soon after alcoholic drinks. massive bilateral eyelid swellingcan constitute diagnostic pitfalls and therapeutic challenges to generalpractitioners with a DE CASOS70(1) , 16:11169 Arq Bras Oftalmol. 2007;70(1):169-71170 Alcohol-related massive eyelid swelling : case reportareas. The huge symmetrical enlargement impaired the visiondue to closure of the eyes, and mid third of the face and theupper lip were also affected (Figure 1). The oral cavity, teethand tongue showed no abnormalities. There was no evidenceof parotiditis, rosaceous lymphedema, scleredema, or skininfection. The ophthalmologic examination resulted normal,except for the massive bilateral eyelid swelling of elastic con-sistency.

5 The stigmata of cardiac, endocrine, hepatic, renal, orstorage diseases were absent. The cranial nerves and the vitalsigns were normal. Laboratory tests showed high levels ofgamma-glutamyltransferase, aminotransferases, and 420 IU/mltotal IgE. The titers of antineutrophil cytoplasmic antibodieswere normal. No abnormalities were found in the complementsystem. The skin-prick tests against aeroallergens, and thepatch tests for contact hypersensitivity resulted negative. Theblood count cells, the urinalysis, the levels of electrolytes,calcium, glucose, albumin, and prothrombin activity were allnormal. The tests of renal and thyroid functions and the chestX-ray resulted normal. Positive results were found on scre-ening for alcohol, but neither clinical findings nor laboratoryparameters characterized liver cirrhosis. Without medication,after a watchful waiting period of two weeks following ethanolabstinence, the facial edema spontaneously regressed; fur-ther, total IgE serum level progressively decreased until rea-ching its normal limit.

6 Skin sample from the right inferior eyelidshowed no evidence of extracellular deposits, granulomas orlymphatic changes (Figure 2). The patient persisted withouteyelid swelling , maintaining alcohol abstinence for more thantwo not entirely clear mechanisms, alcohol users presenthypersensitivity reactions, as exercise-induced anaphylaxis,angioedema, asthma attacks, food allergies, urticaria and IgE-mediated reactions(9). Moreover, alcoholic liver disease canplay a role in the genesis of allergic skin reactions(12); andalcohol intake has been associated with distinctive skin chan-ges and exacerbation of dermatologic disorders(9,13).This nonatopic chronic alcoholic patient presented severedisfiguring edema restricted to the orofacial region, and theepisodes occurred, exclusively, soon after drinking differential diagnosis of chronic facial edema includeslocal and systemic conditions(3).

7 In the present case , the fin-dings favor the hypothesis of an ethanol- related orofacialedema, and hypersensitivity reaction after alcoholic drinks. Amajor concern was about the differential diagnosis with con-tact dermatitis, recurrent idiopathic angioedema(14), and themonosymptomatic presentation of the Melkersson-Rosenthalsyndrome(7). These, and the other above mentioned conditions,were ruled out based on the clinical data, complete question-naire, patch testing, and skin biopsy. Although one can hard-ly prove that alcohol was the sole stimulus in the presentcase; as a whole, the data strongly indicate the major role ofethanol in the genesis of the eyelid swelling . Moreover, after along period of surveillance without medications, the patientFigure 1 - Conspicuous orofacial swelling , with intense enlargementand total closure of the eyelids.

8 Telangiectasias and solar melanosismay also be 2 - Micrograph of skin sample showing superficial mononuclearperivascular infiltrate, slight dermic fibrosis and vascular prolifera-tion. No evidence of granulomas, extracellular deposits or lymphaticstasis was disclosed. Hematoxylin and eosin stain; original magnifi-cation x (1) , 16:11170 Arq Bras Oftalmol. 2007;70(1):169-71 Alcohol-related massive eyelid swelling : case report 171remains in alcohol abstinence and entirely free of the repetiti-ve episodes of orofacial eyelid swelling with impaired vision may be related toalcohol ingestion. Alcohol intake is associated with exacerba-tions of existing dermatologic disorders. Alcoholism can be in-volved in angioedema, anaphylaxis, and IgE-mediated socioeconomic status may enhance the severity ofalcohol- related skin changes following chronic heavy drinking seem tobe massive eyelid swelling can also constitu-te a diagnostic pitfall in clinical palpebral maci o relacionado ao uso de lcool tem sidoraramente descrito.

9 O diagn stico diferencial inclui condi eslocais e sist micas. O pr prio lcool pode estar associado comrea es dermatol gicas de hipersensibilidade, surgindo logoap s uso de bebidas alco licas. Edema palpebral bilateralmaci o pode constituir embara os diagn sticos e desafiosterap uticos para os cl : Alcoolismo/complica es; Edema; P lpebras;Linfedema; Relatos de casos [tipo de publica o]REFERENCES1. Spallek G, Buttgereit F, Audring H, Hiepe F. Persistent facial swelling ofunclear etiology. The differential diagnostic considerations. Hautarzt. 1997;48(11):828-33. Id: Marzano AV, Vezzoli P, Alessi E. Elephantoid edema of the eyelids. J EurAcad Dermatol Venereol. 2004;18(4) Bernardini FP, Kersten RC, Khouri LM, Moin M, Kulwin DR, MutasimDF. Chronic eyelid lymphedema and acne rosacea.

10 Report of two 2000;107(12) Ioannidou DI, Krasagakis K, Stefanidou MP, Karampekios S, Panayiotidis J,Tosca AD. Scleredema adultorum of Buschke presenting as periorbital edema:a diagnostic challenge. J Am Acad Dermatol. 2005;52(2 Suppl 1) Litvyakova LI, Bellanti JA. Orofacial edema: a diagnostic and therapeuticchallenge for the clinician. Ann Allergy Asthma Immunol. 2000;84(2) Lai TF, Leibovitch I, James C, Huilgol SC, Selva D. Rosacea lymphoedemaof the eyelid . Acta Ophthalmol Scand. 2004;82(6) Nossa LMB, Costa AL, Marback RL. S ndrome de Melkersson-Rosenthal:estudo cl nico-patol gico de um caso. Arq Bras Oftalmol. 2001;64(6) Wohlrab J, Lueftl M, Marsch WC. Persistent erythema and edema of themidthird and upper aspect of the face (morbus morbihan): evidence of hiddenimmunologic contact urticaria and impaired lymphatic drainage.