Bilateral dacryoadenitis as a presenting symptom of an extra-ocular disease.

A 49-year-old woman, with no medical history, presented with bilateral swollen eyelids, progressive conjunctivitis and proptosis for the last month (figure 1). She was referred by the ophthalmologist because an underlying disease was suspected. Magnetic resonance imaging of the orbitae showed bilateral enlargement of the lacrimal glands (figure 2). Treatment by the ophthalmologist with antihistamines, topical corticosteroids and antibiotics had no effect. She had no other complaints. Physical examination showed evident swelling of both eyes without nasal or oral inflammation. Laboratory investigations showed: C-reactive protein 109 mg/l (0-10), haemoglobin 6.6 mmol/l (7.5-10.0), with a normal cellular volume, leucocytes 10.0 x 10/l (4.0-10.0), and a normal serum creatinine; IgG4 levels were within normal limits. Urinalysis showed erythrocytes (3+), leucocytes (2+) and protein (1+). PHO TO QU I Z