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JAMA Ophthalmology Clinical Challenge
September 2014

Diffusely Swollen Eyelid

Author Affiliations
  • 1Department of Ophthalmology, University of California, San Francisco, School of Medicine
JAMA Ophthalmol. 2014;132(9):1145-1146. doi:10.1001/jamaophthalmol.2014.1964

A 55-year-old man presented with diffuse, painful swelling of the right upper eyelid (Figure, A). The patient’s medical history was notable for rheumatoid arthritis that had been well controlled with methotrexate for 15 years. The lesion was first noted 6 months prior to presentation and was initially diagnosed as a chalazion. The nodule increased in size during the next several months despite conservative measures including warm compresses. A biopsy revealed a mixed inflammatory infiltrate without evidence of neoplasia, supporting a diagnosis of chalazion. Intralesional triamcinolone was then administered. Despite an initial decrease in lesion size, 6 weeks postinjection, new-onset ipsilateral extraocular motility deficits and palpable preauricular lymphadenopathy were noted. A magnetic resonance image revealed an infiltrative process in the involved eyelid and lymphadenopathy (Figure, B and C). A second biopsy of the eyelid lesion revealed large, atypical lymphocytes diffusely positive for CD20 and negative for CD5 and Bcl-1 (Figure, D-G), supporting a diagnosis of diffuse large B-cell lymphoma (DLBCL). Findings from systemic evaluation, including complete blood cell count, serum protein electrophoresis, serum lactate dehydrogenase, and whole-body positron emission tomography, were unremarkable.

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