Clinical Images: Dacryoadenitis as the herald symptom for systemic lupus erythematosus.

The patient, a 39-year-old gravida 3 para 2 African American and Native American woman, presented to the emergency department with left-sided periorbital swelling and pain. She endorsed additional symptoms of orthopnea, paroxysmal nocturnal dyspnea, nausea, and sicca for the preceding days. She denied having fever, photosensitive rash, oral ulcerations, Raynaud's phenomenon, or myalgia. The examination was notable for a blood pressure of 132/86 mmHg, diffuse nonpitting edema, and significant left-sided periorbital edema (A). Pertinent lab results include a hemoglobin level of 9.1 g/dl, a creatinine level of 0.68 (0.59-1.04), an albumin level of 2.2 (3.5-5.0), a urinalysis result of 3+ protein and 2+ blood, and a protein/creatinine ratio of 15.625 (<0.2). Rheumatologic testing results were positive for antinuclear antibodies, normal for complements, and negative for anti-Smith, double-stranded DNA, SS-A, SS-B, rheumatoid factor, and anti–cyclic citrullinated peptide.T2 fluid-attenuated inversion recovery sequence orbital magnetic resonance imaging showed left preseptal and lacrimal gland edema not extending to the orbital apex consistent with dacryoadenitis (B). The sample from a renal biopsy performed 5 weeks after the initial presentation was reviewed. Light microscopy demonstrated diffuse thickening of the glomerular basement membranes (square box) with rare segmental spikes (arrow) (Jones methenamine sliver stain; original magnification × 20) consistent with membranous pattern of injury. The inset image shows strong granular staining of the capillary loop with immunoglobulin G on immunofluorescent histology (original magnification × 20) (C and D). A lacrimal gland biopsy showed nonspecific inflammation with negative immunoglobulin G4 (IgG4) staining. She was diagnosed with systemic lupus erythematosus (SLE), and therapy was initiated with mycophenolate mofetil in addition to a prednisone taper. Although dacryoadenitis is typically associated with Sjögren syndrome, IgG4 disease, or sarcoidosis, patients should also undergo evaluation for SLE (1, 2). Disclosure Form: Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.