Fig. 1

Isolated facial edema and subclinical facial muscle involvement. At initial presentation there was bilateral swelling of the face and of the left eyelid, accompanied by eczematoid eruption on the chin (a). After approximately two weeks of medium-dose glucocorticoid therapy the edema and the lesions were completely resolved (b). However, combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining remission at a prednisolone dose lower than 15 mg per day. At the last relapse, there was marked aggravation of facial and eyelid edema (c). Gadolinium-enhanced MRI scan of the head shows diffuse edematous change with enhancement of bilateral masticator muscles (d, masseter muscle [yellow arrow] and lateral pterygoid muscle [black arrow]). There was also swelling of bilateral extra-ocular muscles and edematous change with fat infiltration in the subcutaneous tissues of the anterior scalp, periorbital area, buccal space, and anterior cervical fascia (not shown)