Jenny C Dohlman, Natalie Wolkow, Michael K Yoon
A 28-year-old man with 2 months of lymphadenopathy, unintentional weight loss, and fevers of unknown etiology initially presented with OD pain, swelling, and binocular diplopia that began while he was sleeping on his right side at home. On examination, he was noted to have 4 mm of relative proptosis and limitation of upgaze, abduction, and adduction but no signs of optic nerve compromise. MRI orbits revealed a large, well-circumscribed, mixed signal intensity mass in the superomedial right extraconal orbit with minimal enhancement and layering T2 hypointense material suggestive of subperiosteal hematoma (Fig. A). Three days later while admitted for antibiotics and further workup, and 2 days after a right-sided cervical lymph node biopsy, the patient developed left-sided eye pain, swelling, and limitation of upgaze, abduction, and adduction. An interval MRI of the orbits revealed the same right orbital mass with new T1 hyperintensity and less susceptibility without enhancement, consistent with evolving blood products, as well as a new left T1 hypointense intraconal mass without enhancement, consistent with new subperiosteal hematoma (Fig. B). The patient was found to be anemic with hemoglobin of 8.8 and hematocrit of 29.1, but prothrombin time and international normalized ratio were within normal limits at 13 and 1.1, respectively. The patient had improvement of ocular symptoms after receiving a 3-day pulse of high-dose steroids and was discharged on a prednisone taper. The results of his systemic workup, including extensive infectious and inflammatory testing, multiple lymph node biopsies, and a bone marrow biopsy were nondiagnostic and consistent with a reactive process
Hanbin Lee, Huw Oliphant, Siriram Vundavalli, Mark Taylor, Michael Koenig, Carl Hardwidge, Sorin Bucur, Saul N Rajak
Acquired unilateral alacrima as a presenting sign of an intracranial tumor is exceptionally rare, and only described once previously in a case of nasopharyngeal carcinoma. The authors present a 32-year-old female patient who presents with a year-long history of alacrima and arhinorrhea. She was subsequently diagnosed with a petroclival chondrosarcoma extending into Meckel’s cave and the cavernous sinus and underwent surgical debulking. To the authors’ knowledge, this is the first reported case of acquired unilateral alacrima as a presenting feature of a skull base chondrosarcoma. This case serves to remind general ophthalmologists and oculoplastic surgeons alike that acquired alacrima may be the presenting feature of serious intracranial disease.
Sonal P Yadav, Anirudha Puntambekar, Tushar Patil, Rahul Deshpande
Eyelid metastases are relatively rare, and they can occasionally lead the way to an unknown primary malignancy elsewhere. The authors report a case of 65-year-old diabetic gentleman with a right-sided eyelid lesion that was present for 1 month and turned out to be a presenting sign of a previously undiagnosed pancreatic adenocarcinoma. The eyelid mass had been treated elsewhere for 2 weeks for a presumed infectious lesion, using systemic antibiotics and was then referred to us in view of no response. The right-sided lesion involving the subbrow and eyelid area was tender and showed surface ulceration, as well as induration with scabbing. An incision biopsy of the mass was performed followed by computed tomography imaging. Histopathologic findings were suggestive of adenocarcinoma of a probable secondary origin. A whole-body positron emission tomography (PET) scan along with raised serum tumor markers (carcinoembryonic antigen 125 [CEA 125] and carbohydrate antigen 19-9 [CA-19-9]) was helpful in diagnosing a stage IV probable primary carcinoma of the pancreas, with metastasis to paraaortic nodes, liver, lungs, and eyelid. After a detailed systemic work-up, the patient was put on systemic chemotherapy with carboplatin and capacitabane. He responded well to the treatment. At a follow up of 12 months, upon clinical examination and PET imaging, he showed a complete resolution of eyelid, lung, and liver disease and a near-complete resolution of the pancreatic lesion. This case delineates the role of a prompt biopsy and histopathologic evaluation of an atypical eyelid mass in diagnosing asymptomatic primary malignancy
Ann Q Tran, Catherine J Choi, Zakeya Al-Sadah, Xiao Yi Zhou, Sander Dubovy, Neal E Rothschild, Bradford W Lee
An 85-year-old man presented with a 6-month history of worsening left proptosis and painless ophthalmoplegia. Imaging revealed an extensive intraconal and extraconal tumor extending to the level of the optic foramen, as well as the scalp, cheek, and the nasal bridge. Incisional biopsy was consistent with lacrimal gland adenocarcinoma. The patient underwent a left orbital exenteration followed by immunotherapy with pembrolizumab. The treatment was stopped prematurely after 5 cycles due to development of autoimmune colitis. Four months later, the patient developed new contralateral disease in the right orbit and an incisional biopsy again showed lacrimal gland adenocarcinoma. Following the incisional biopsy, no further treatment was administered, but over the ensuing 6 months, there was dramatic spontaneous regression of the tumor both clinically and radiographically. At 28 months, the patient is still alive with relatively stable disease.