Facial swelling and eosinophilia in a 44-year-old woman

Abstract

CHIEF COMPLAINT A 44-year-old woman was referred to our institution for evaluation of facial swelling and progressively increasing eosinophilia, which began 2 months before she was seen. The patient first noticed right-sided temple and periorbital angioedema 2 days after completing a 10-day course of cefuroxime (Ceftin, GlaxoSmithKline, Research Triangle Park, NC) for a presumed upper respiratory infection/flulike illness. A complete blood count done 4 days after cefuroxime treatment was completed revealed an eosinophil count of 1,384 cells/mm3. The patient was then evaluated by an otolaryngologist and treated with a methylprednisolone acetate (Medrol Dose Pak Pharmacia, Peapack, NJ) and cetirizine hydrochloride (Zyrtec, Pfizer, New York, NY), which resulted in complete resolution of swelling. Angioedema recurred 2 days after she completed the methylprednisolone course (GlaxoSmithKline, Research Triangle Park, NC). Because of recurrent symptoms, she was started on zafirlukast (Accolate, AstraZeneca, Wilmington, DE) 20 mg twice a day and ranitidine (Zantac, GlaxoSmithKline) 75 mg twice a day. Angioedema persisted. Two weeks before the patient was seen in our institution, her eosinophil count increased to 5,742 cells/mm3. At that time, she was given a second methylprednisolone course. The angioedema again resolved completely and then recurred several days after methylprednisolone was completed. Two days before we saw her, her eosinophil count increased further to 13,050 cells/mm3. The patient was seen at our institution complaining of facial and upper extremity swelling, a 16-pound weight gain over the past 2 months, fatigue, and a nonpruritic rash on bilateral antecubital fossae for the past 2 to 3 days. She denied any headaches, shortness of breath, chest tightness, abdominal pain, bloody stools, lower extremity edema, or numbness/tingling in any extremities. MEDICAL HISTORY The patient had a history of osteoarthritis and mild mitral regurgitation. Surgical history was significant for breast biopsy of a benign tumor 6 years before and a total abdominal hysterectomy and bilateral oopherectomy 3 months before she was seen. She experienced allergy to penicillin 1.5 years earlier, which manifested as self-limited hives. There was no history of asthma, urticaria, food allergy, or recurrent respiratory infection.