[34F] With persistent eyelid swelling and rash

Patient Description

A 34-year-old female has been experiencing firm, puffy, and rough swelling in her eyelids for the past three months. The swelling began suddenly in one eye and then spread to the other. Along with the swelling, there is a red rash underneath her eyes, and her eyes feel dry. The symptoms are worse upon waking up and late at night when they burn and itch. She also reports vision changes, including seeing moving objects in her peripheral vision that aren't there and floaters. Light discharge is present but not colored. She has extreme sensitivity to light. The patient has seen two doctors; the first diagnosed her with periorbital cellulitis, and the second suggested eczema and recommended seeing an ophthalmologist. She does not have insurance. She finished a course of Bactrim prescribed by the first doctor. She has not noticed any specific triggers for the swelling and has not recently changed skincare products, makeup, or started new medications or eye drops. She has been using a healing balm on the dry skin. She experienced wheezing and dry coughing spells around the same time the eye swelling began, but these episodes have since subsided. She has no recent travel history or exposure to new environments and no known family history of allergies, eczema, or other skin conditions. She has a history of gestational diabetes and was diagnosed with Hashimoto's thyroiditis in February 2023. She underwent surgery to remove a cyst in the maxillary sinus and a Haller cell. Current medications include Xanax (0.5 mg as needed), Metformin (500 mg extended-release tablets twice a day), and Levothyroxine (25 mcg once a day). She is allergic to Doxycycline, which causes leg swelling and a rash. She sometimes takes Goody's headache powders for pain relief.

Arora's Assessment

What might be happening

Based on the symptoms and history you've provided, here are some possible explanations for your condition:

1. Periorbital Cellulitis

Rationale: The first doctor diagnosed you with periorbital cellulitis, which is an infection of the eyelid and surrounding skin. This condition can cause swelling, redness, and discomfort around the eyes.
Typical Treatments: Treatment usually involves antibiotics to fight the infection. Given your history of antibiotic allergies, this could complicate treatment.

2. Eczema (Atopic Dermatitis)

Rationale: The second doctor suggested eczema, which can cause red, itchy, and inflamed skin. Eczema around the eyes can lead to swelling and discomfort.
Typical Treatments: Treatment often includes topical corticosteroids, moisturizers, and avoiding irritants.

3. Chronic Sinusitis

Rationale: You have a history of sinusitis and recent surgery to remove a cyst and a Haller cell. Chronic sinusitis can sometimes cause swelling around the eyes and other related symptoms.
Typical Treatments: Treatment may include nasal corticosteroids, saline nasal irrigation, and sometimes antibiotics if a bacterial infection is present.

4. Allergic Reaction

Rationale: Although you haven't identified a specific allergen, the symptoms could still be due to an allergic reaction, especially given the itching and burning sensations.
Typical Treatments: Treatment usually involves antihistamines, avoiding known allergens, and sometimes corticosteroids.

5. Hashimoto's Thyroiditis

Rationale: Your recent diagnosis of Hashimoto's thyroiditis could contribute to some of your symptoms, such as dry skin and possibly even swelling.
Typical Treatments: Treatment involves thyroid hormone replacement therapy, which you are already taking.

What you can do

Eye Swelling and Rash

See a Specialist: Given the persistence and severity of your symptoms, it's crucial to see an ophthalmologist or a dermatologist for a more detailed evaluation.
Avoid Irritants: Continue to avoid any potential irritants, including nail polish and other skincare products.
Moisturize: Use a gentle, hypoallergenic moisturizer to help with the dryness and rash.
Cold Compress: Apply a cold compress to your eyes to help reduce swelling and discomfort.

Vision Changes

Immediate Attention: Vision changes, especially seeing moving objects that aren't there and floaters, warrant immediate medical attention. Please consult an ophthalmologist as soon as possible.
Document Symptoms: Keep a record of your vision changes, including when they occur and any associated symptoms.

Sinusitis

Follow-Up: Given your history of sinus surgery and ongoing symptoms, a follow-up with an ENT specialist may be necessary to rule out any lingering infection or complications.
Nasal Care: Continue with saline nasal irrigation to help keep your sinuses clear.

General Health

Monitor Thyroid Levels: Ensure that your thyroid levels are regularly monitored and that your medication dosage is appropriate.
Healthy Lifestyle: Maintain a healthy diet, stay hydrated, and get regular exercise to support your overall well-being.

Symptom Tracking

Use MDandMe: Consider using MDandMe to journal your symptoms, track your progress, get insights, and share longitudinal medical notes with your healthcare provider.

What you should look out for

Given the complexity and severity of your symptoms, you should seek medical care as soon as possible. Reasons to seek care even more urgently include:

Worsening Vision: Any sudden or severe changes in vision.
Increased Swelling: If the swelling around your eyes worsens or spreads.
Fever or Pain: The onset of fever or significant pain, which could indicate an infection.
Breathing Difficulties: Any new or worsening respiratory symptoms.

Remember, while I can provide information and suggestions, it's essential to consult with a healthcare professional for a formal diagnosis and appropriate treatment.