Welcome to question of the day #34

Welcome to question of the day #34

Why do some patients complain of chronic puffy swelling around the eyes?

This is a common complaint, often expressed by patients aged 40 and over. They will often have a history of a puffy eye tendency throughout life ‘but it seems to be worsening now’. They will often remember this tendency in one or both parents ‘but it seems like I've it worse than they had it’. The main concern to the patient is usually a cosmetic one. These are the common underlying causes:

Hereditary angioneurotic oedema

This is genetically-based and involves an enzyme deficiency (a serum esterase). The enzymatic deficiency leads to ongoing complement-mediated degranulation of mast cells. Other vaso-active substances may also be involved, but histamine is primarily responsible. The periorbital oedema accumulates due to the increased porosity of periorbital vessels. In some patients, chronic laryngeal oedema is also reported

Chronic atopic blepharoconjunctivitis

This is a ‘simmering’ Type-I hypersensitivity activity. Again, genetically-based and the history includes numerous forms of allergy to environmental substances.

Management

Mast-cell stabilization

Cool compresses

Cool water face washes

Topical mast-cell stabilizers

Oral antihistamines

Avoidance of exacerbating stimuli (if possible)

Reduce intake of as many vaso-active substances as possible.

Trichinosis

infection by Trichinella spiralisfrom eating raw or undercooked pork. Intestinal symptoms-->skeletal muscle aches-->shortness of breath-->generalized facial oedema-->may progress to encephalitis almost always with a high fever almost always gross eosinophilia on white cell count. Teated with thiabendazole and, in acute phases, with analgesics.

Dermatomyositis

Inflammation of connective tissues. This can be acute, subacute, or chronic. General features areoedematous, painful, inflamed muscles, commonly of the major muscles of the hips and shoulders. Oftentimes with generalized involvement of skin and mucous membranes (dermatitis and mouth ulcers are common). About 1/3 of all patients have significant swallowing difficulties. Treatment involves anti-inflammatories-often corticosteroids and non-steroidal anti-inflammatories.

Passive, generalized accumulation of interstitial fluids

Sometimes associated with congestive heart failure. Sometimes associated with chronic renal disease. Often associated with menstruation. Often associated with pregnancy. Treatment involves treatment of the primary condition.