Spot Diagnosis

Bilateral Eye Swelling

Catarina Santiago Gonçalves1,2, Filipa Urbano1, José Gonçalo Marques1,3, Ana Mouzinho3
1Division of Infectious Diseases and Immunology, Department of Pediatrics, Santa Maria Hospital, Lisbon University Hospital Center, Lisbon, Portugal, 2Department of Pediatrics, Women and Child Health Services, Holy Spirit of Evora Hospital, Lisbon, Portugal, 3University Clinic of Pediatrics, Faculty of Medicine, University of Lisbon, Lisbon, Portugal

Address for Correspondence: Catarina Santiago Gonçalves, Largo do Sr. da Pobreza, 7000-811 Évora, Portugal.
Keywords : Dacryoadenitis, adenovirus, eyelid edema, chemosis, conjunctival pseudomembrane.
Question :
A previously healthy 6-year-old boy was admitted to the emergency department with fever, cervical lymphadenopathy, bilateral eyelid edema and erythema, with almost complete closure of the palpebral fissures, exuberant chemosis and photophobia (Figure 1). He had no recent history of respiratory tract infections, no apparent cutaneous portal of entry or contact with someone with similar symptoms. On physical examination, pupils were equally round and reactive to light, but the evaluation of extraocular muscle movements and visual field testing were not possible due to eyelid edema. Computed tomography (CT) of the orbits and sinuses revealed bilateral enlargement of lacrimal glands (Figure 2). Treatment with systemic amoxicillin + clavulanic acid and topical prednisolone and chloramphenicol was started, and he was regularly observed by an ophthalmologist. He responded well to treatment and resolution of eyelid edema, conjunctival pseudomembranes were observed. Serological studies were consistent with acute adenovirus infection (positive IgM/ negative IgG antibodies) and past Epstein-Barr virus (EBV) infection (positive viral capsid antigen (VCA) IgG antibodies; negative VCA IgM antibodies; positive EBV nuclear antigen (EBNA)1 IgG antibodies). The patient had a full recovery and remained well two years later.

Figure 1. Edema and erythema of the upper eyelids and bilateral chemosis.

Figure 2. Computed tomography of the orbits showing bilateral enlargement of the lacrimal glands (blue arrows).

What is the diagnosis?
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