The frequency of granulomatous lacrimal gland inflammation as a cause of lacrimal gland enlargement in patients without a diagnosis of systemic sarcoidosis

Autoimmune disease of head and neck, imaging, and clinical review

Autoimmune disease of the head and neck (H&N) could be primary or secondary to systemic diseases, medications, or malignancies. Immune-mediated diseases of the H&N are not common in daily practice of radiologists; the diagnosis is frequently delayed because of the non-specific initial presentation and lack of familiarity with some of the specific imaging and clinical features. In this review, we aim to provide a practical diagnostic approach based on the specific radiological findings for each disease. We hope that our review will help radiologists expand their understanding of the spectrum of the discussed disease entities, help them narrow the differential diagnosis, and avoid unnecessary tissue biopsy when appropriate based on the specific clinical scenarios.

Autoimmune markers in screening for orbital inflammatory disease

PURPOSE

Immunogenic causes of inflammation may be difficult to differentiate in the work-up of orbital inflammatory disease. The study aims to investigate the utility of autoimmune markers in the screening for orbital inflammation. Markers studied included angiotensin-converting enzyme (ACE), antinuclear antibody (ANA), anti-neutrophilic cytoplasmic autoantibodies (ANCA), extractable nuclear antigen (ENA), anti-cyclic citrullinated peptide (Anti-CCP) and anti-double stranded DNA antibody (Anti-dsDNA antibody).

METHODS

A retrospective single-centre study of consecutive patients with non-infective orbital inflammation screened for autoimmune markers at presentation. Serology was interpreted alongside clinical course and other investigations (e.g. radiographic features and histopathology). Tabulated data and Pearson's Chi-square allowed analysis of trends between serology, diagnosis and the decision to biopsy.

RESULTS

79 patients, between 1999 and 2021, were included (50 females, mean age was 50.4 ± 17.4 years). 28 (34.6%) patients had specific orbital inflammation and 53 (65.4%) patients had non-specific orbital inflammation (NSOI). Of the 12 patients with positive serology and a specific diagnosis, only 5 (41.7%) patients had concordant serological results. There was no association between serology results and the patient undergoing biopsy (P = 0.651). Serology was unable to exclude nor differentiate NSOI from other specific conditions and ANA had limited discriminatory value between specific conditions and NSOI.

CONCLUSION

Serological testing alone may not provide a clear direction for further investigation of orbital inflammation and a biopsy may occur independently of the serological results. The value of autoimmune markers may lie in subsequent follow-up as patients may develop suggestive symptoms after an indeterminate positive result or initially seronegative disease.

Sarcoidosis presenting as bilateral lacrimal gland swelling: a pediatric case report

BACKGROUND

To describe a case of pediatric sarcoidosis which initially presented as papillary conjunctivitis before manifesting as bilateral lacrimal gland swelling without other known systemic involvement.

CASE PRESENTATION

A 10-year-old female presented to the pediatric ophthalmology clinic with complaints of bilateral eyelid swelling, tearing and itching for approximately 1 month. Her history and exam were most consistent with allergic conjunctivitis, for which she was started on a standard topical regimen. Despite initial improvement, she re-presented with significantly worsened eyelid swelling and minimal allergic symptoms. Enlargement of the lacrimal glands were palpable at this time. Lacrimal gland biopsy was obtained which demonstrated noncaseating granulomas. Systemic workup did not reveal evidence of disease involvement elsewhere.

CONCLUSIONS

Sarcoidosis in the pediatric population may present in a myriad of ways and is well-known to mimic other disease entities. We present a case of pediatric sarcoidosis which presented initially as papillary conjunctivitis before manifesting as bilateral lacrimal gland swelling without systemic involvement.

Non-infectious Dacryoadenitis

Dacryoadenitis is an inflammation of the lacrimal gland that may have various etiologies with similar presentations. Despite more recent elucidation of specific causes, the management has remained largely unchanged. Hence, the condition remains under biopsied with the rationale that empirical treatment with corticosteroids is effective for many of the causes. Dacryoadenitis, however, dacryoadenitis can be the presenting sign of an undiagnosed systemic disease and a mimick for lymphoma; hence, tissue diagnosis and systemic investigations play a vital role. A significant proportion of dacryoadenitis has a specific etiology, and IgG4-related dacryoadenitis is more frequently identified as a cause. We summarize the different types of immune-mediated dacryoadenitis, their clinical findings, histopathology, management, and prognosis. We have also highlighted and formulated practice guidelines for diagnosis and effective treatment based on the underlying systemic disease.

Computed Tomography Evaluation of Normal Lacrimal Gland Dimensions in the Adult Pakistani Population

Objectives To estimate the normal dimensions of lacrimal glands (LGs) in the Pakistani population using computed tomography (CT) scan and to determine the associations of LG dimensions with age, sex, and laterality. Methods The study population included subjects aged ≥16 years without orbital pathology who underwent CT evaluation of both the right and left LGs at Dr. Ziauddin University Hospital from June 2018 to November 2019. The mean axial length (AL), axial width (AW), coronal length (CL), and coronal width (CW) of each LG were measured separately. Results The 108 subjects enrolled in this study included 75 (69.4%) men and 33 (30.6%) women, with a mean age of 49±20 years. Right and left LG dimensions were similar, including mean AL (13.53±1.80 mm vs. 13.35±1.72 mm), mean AW (4.20±0.81 mm vs. 4.05±0.93 mm), mean CL (15.46±1.97 mm vs. 15.26±1.87 mm), and mean CW (3.99±0.80 mm vs. 3.86±0.81 mm). The AL of both LGs and the CL and CW of right but not left LGs were significantly lower in women than in men. Age showed significant correlations with the AL and CL of both LGs. Conclusion These findings establish the normal range of LG dimensions in adult Pakistani populations. Some LG dimensions are smaller in women than in men, as well as correlating with age.

Autoimmune Granulomatous Inflammation of Lacrimal Glands and Axonal Neuritis Following Treatment With Ipilimumab and Radiation Therapy

Immune checkpoint inhibitors such as anti-CTLA-4 (cytotoxic T-lymphocyte–associated protein 4), anti PD-1 (programmed cell death protein 1) and PD-L1 (programmed cell death protein-ligand 1) monoclonal antibodies are emerging as standard oncology treatments in various tumor types. The indications will expand as immunotherapies are being investigated in various tumors with promising results. Currently, there is inadequate identification of predictive biomarkers of response or toxicity. Unique response patterns include pseudoprogression and delayed response. The use of immune checkpoint inhibitors exhibit an unique toxicity profile, the immune-related adverse events (irAEs). The most notable immune reactions are noted in skin (rash), gastrointestinal track (colitis, hepatitis, pancreatitis), lung (pneumonitis), heart (myocarditis), and endocrine system (thyroiditis, hypophysitis). We present a patient with metastatic adenoid cystic carcinoma of the left submandibular gland with granulomatous inflammation of the lacrimal glands and axonal neuritis of the cervical and paraspinal nerves following treatment with ipilimumab and radiation therapy.

Normal Lacrimal Gland Volumes by Magnetic Resonance Imaging and the Relationship of Lacrimal Gland Volume to Orbital Size

PURPOSE

The aim of this study was to measure volumes of normal lacrimal glands (LGs) using magnetic resonance imaging in African-Americans (AAs) and whites and to evaluate relationships of LG volumes to demographic factors.

METHODS

A retrospective chart review was performed searching for "optic neuropathy" and "optic neuritis," cross-referencing patients who had orbital MRI with and without contrast. Cases were excluded with known history of orbital trauma or surgery, previous diagnoses known to affect LG size, and poor image quality. LGs were outlined in consecutive axial and coronal slices, and volumes were generated using OsiriX software; cross-sectional area of the orbit was measured by outlining the bony orbit in largest axial section.

RESULTS

One hundred orbits from 50 patients were included (26 AAs, 24 whites). Mean LG volumes as measured in coronal and axial section were 0.714 and 0.671 cm, respectively; mean orbital area was 10.42 cm. Axial orbital size was found to be highly correlated (P < 0.01) with LG volume. No significant correlation was found with LG volume and age, sex, race, or laterality.

CONCLUSIONS

This article presents normal values for LG volumes by MRI of AAs and whites. LG volumes were highly correlated with orbital size, a relationship which has not been explored in the recent literature. Such an assessment of LG size relative to patients' orbital dimensions may be more clinically useful than comparison to population-based measures of normal LG volume alone. We found no statistically significant relationship between LG volume and race, sex, age, or laterality.

Evaluation of Lacrimal Gland Dimensions and Volume in Turkish Population with Computed Tomography

INTRODUCTION

Computed tomography (CT) is a widespread method for evaluating head and neck pathologies. The lacrimal glands (LGs) are usually visible in routine head and neck CT scans. LG pathologies usually manifests with changes in gland sizes, so it is important to know the normal values of the LG dimensions and volume. The LG sizes may change with age, gender and race. The normal values of LG dimensions and volume in Turkish population was not reported before.

AIM

The aim of this study was to evaluate the dimensions and volumes of the LGs by CT in a Turkish population.

MATERIALS AND METHODS

Two hundred seventeen consecutive paranasal CT scans of subjects evaluated retrospectively. Measurements of LG dimensions were performed in axial and coronal paranasal CT images. The LG volume was calculated with Aquarius software by outlining the gland in all consecutive axial images.

RESULTS

Four hundred orbits of 200 subjects were included to the study. The mean axial LG length in right and left orbits were 16.2±2.0 mm and 16.0±2.0 mm and the mean axial width of the right and left orbits were 4.1±0.7 mm and 4.0±0.7 mm. The right and left LG mean values for coronal length and width were equal 18.3 ±2.2 mm and 4.1±0.7mm respectively. The mean LG volume was 0.617±0.210 cm(3) in right and 0.597±0.197 cm(3) in the left orbits. There were statistically significant differences in the axial width and volume of the LG according to sides, however there was no significant difference according to gender. Age and LG measurements were negatively correlated.

CONCLUSION

Our study may serve as a guide to determine the average values of the LG measurements in Turkish population and find out the orbital pathologies that involves the LG.

The many facets of dacryoadenitis

PURPOSE OF REVIEW

To review the spectrum of lacrimal gland inflammation, with particular reference to the old condition, idiopathic dacryoadenitis, and the new, immunoglobulin G4 (IgG4)-related dacryoadenitis.

RECENT FINDINGS

Idiopathic dacryoadenitis remains the most common inflammatory lesion of the lacrimal gland, for which surgical treatment is successful. There is mounting evidence that the presence of IgG4-positive plasma cells in a lacrimal gland specimen is nonspecific, for being found in other inflammatory lacrimal gland lesions, even lymphoproliferative ones. To identify IgG4-related dacryoadenitis, particularly when there is no documented disease elsewhere, the criteria have been strengthened toward abundant IgG4-positive plasma cell counting.

SUMMARY

The gold standard of diagnosis of noninfectious lacrimal gland inflammation is tissue biopsying, which is commonly therapeutic in the case of idiopathic dacryoadenitis. Although it was initially suggested that IgG4-related dacryoadenitis is a possible cause of idiopathic dacryoadenitis, it becomes obvious that it has more resemblance to the lymphoproliferative tumors.