A 55-year-old female patient presented to us with a 10-day history of malaise, lethargy, and fever up to 39.50 C accompanied by rigors. She also complained of diffuse myalgias, arthralgias, and bilateral facial edema. Her past medical history was significant for a modified mastectomy for invasive breast cancer in 2000 but she is free of disease 6 years later. There was no history of trauma. She admitted that she had botulinum toxin injections in the forehead 4 years ago but there was no prosthesis in the periorbital area (neither silicone nor fat).

On examination, her blood pressure was 130/70 mm Hg and she was feverish (390 C). Pulse rate was 90 bpm regular and respirations were 18/ minute. There was marked edema of the face, especially in the periorbital and malar areas (Figure 1), and this was accompanied by erythema and sensitivity. There was no associated feeling of pruritus of the aforementioned area. A scar from the previous surgical operation in the breast area was evident.

Laboratory examinations showed leucocytosis (12480 /mm3 with a left shift), normal eosinophil count, increased C-reactive protein [11.4 mg/dl (normal values 0-0.5)], and increased erythrocyte sedimentation rate [70 mm/1st hour (normal 0-20)]. Creatinophosphokinase levels were increased [1453 IU/lt (normal 21-215)]. Immunoglobulin levels were increased for IgA [550 (normal 55-377) mg/dl] and IgE [(696 IU/lt (normal 0-200)], Serum protein electrophoresis was normal. C1 esterase inhibitor levels were normal [339 mg/lt (normal 210-390)]. Antinuclear autoantibodies, anti-dsDNA and anti-Sm were all negative. Serology testing was negative for Trichinella spirallis and C. trachomatis. Magnetic resonance angiography of the brain vessels was normal. MRI imaging confirmed the presence of edema in the periorbital area. Electromyography of the muscles of the upper and lower limbs was normal.

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