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Images of Memorable Cases: Case 75

Module by: Herbert L. Fred, MD, Hendrik A. van Dijk. E-mail the authorsEdited By: Frederick Moody

http://rup.rice.edu/memcases-button.jpg

Case_75-pres1-1.jpg

This 51-year-old nurse presented with swollen eyelids, excessive tearing, and photophobia of 18 months’ duration. During that time, she had consulted with two internists and four ophthalmologists before the diagnosis ultimately emerged. Topical corticosteroid preparations and other symptomatic treatment had afforded no relief. Except for her eyes, she felt perfectly fine.

The mystery in this case began to clear when a CT scan of the pelvis showed osteolytic and osteoblastic lesions. All previous studies, including blood counts, chest radiograph, bone scan, mammograms, and CT scans of the head and orbits, had given normal results. At this time, a thorough physical examination disclosed several cutaneous nodules, 0.5 to 1 cm in diameter, on the patient’s upper torso. Biopsy specimens from one of these nodules and from the right lower eyelid showed identical findings: metastatic infiltrating lobular carcinoma of the breast.

Symmetric thickening and induration of the eyelids, presumably from lymphatic obstruction by tumor cells, is a rare form of lid metastases, occurring almost exclusively in women with breast carcinoma. Accordingly, the patient received methotrexate, cyclophosphamide, and 5- fluorouracil. Within two months, her skin nodules had regressed substantially, and her eyelids had returned to normal.

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