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• W4230344836 abstract "Cephalic tetanus is a subtype of tetanus in which cranial nerve palsies often precede trismus. We present a case of cephalic tetanus in a woman in whom an unusual and incomplete palsy of the voluntary muscles occured. She denied trauma. As there was a delay in the diagnosis of cephalic tetanus, respiratory arrest was narrowly avoided. Case Report A 64-yr-old Japanese woman with a 3-day history of left facial palsy came to our pain clinic Figure 1. She had a right facial palsy approximately 15 yr earlier that was treated by stellate ganglion block. She indicated that the current symptom was quite similar. Although her left sternocleidomastoid muscle was slightly spastic, a left stellate ganglion block was performed daily for 2 days using 5 mL of 1% lidocaine, and betamethasone 1.5 mg, vitamin B12 1.5 mg, and adenosine triphosphate disodium 180 mg were given orally and daily. On the third day, the patient complained of dysphagia, hoarseness, and a locking jaw that began the previous afternoon. A neurologist noted left-lower-quarter facial spastic palsy and painful tonic seizure and prescribed oral carbamazepine 0.3 g daily. She did not complain of pain, and neither a wound nor an inflammatory site was evident. Therefore, the neurologist suspected an intracranial lesion and ordered a magnetic resonance image (MRI) examination. On the fourth day, the patient returned to our hospital complaining of a progressively locking jaw. As dysphagia prevented her from eating for 2 days, prompt hospitalization was considered necessary. In the early morning on the fifth day, and 7 h after admission, a convulsion occurred in the face and neck and spread to the upper part of her body. Apnea and cyanosis developed, and a nasotracheal intubation was blindly done immediately. Convulsion, however, persisted and increased. The intravenous administration of diazepam 2.5 mg was transiently effective. When the convulsion ceased, the patient showed a good level of comprehension. There was no evidence of tumor, inflammation, or cerebral vascular disease on the computed tomography scan or on the MRI. Cerebrospinal fluid examination was normal. Continuous infusion of thiamylal 50 mg/h was started to control convulsions, and intermittent positive pressure ventilation was initiated. Intravenous hyperalimentation and antibiotics were also started.Figure 1: Patient as seen at the first consultation. She complained of left facial weakness, but there was no laterality in the orbicularis oculi muscles (hidden) and nasolabial sulci were clear.On the fourth day of admission, a strategy to treat tetanus was determined, despite the absence of any traumatic episode. Human antitetanus immune globulin (Tetanobulin-I; Green Cross, Osaka, Japan) 3000 IU was administered intravenously for 8 days. Arterial blood pressure was controlled with dopamine hydrochloride 6-8 micro gram centered dot kg-1 centered dot min-1. Convulsion was suppressed with thiamylal 200 mg/h under intermittent positive pressure ventilation in a light-shielded room. The convulsion gradually disappeared, and thiamylal was discontinued. Respiration soon became spontaneous, and the patient was weaned from mechanical ventilation. After this initiation of tetanus toxoid, her general condition improved and she was discharged ambulatory on the 69th day after the onset of left facial palsy Figure 2.Figure 2: Clinical course. Onset = initiation of left-lower-quarter facial palsy. Days indicate days from the onset. IPPV = intermittent positive pressure ventilation; # = SIMV (simultaneous intermittent mandatory ventilation); CPK = creatine phosphokinase; PIPC = piperacilline 4.0 g/d; PAPM/BP = panipenem/betamipron 1.0 g/d; @ = as an ambulatory patient of our pain clinic.Discussion As tetanus has become a rare disease in the developed world (30 to 50 patients with tetanus are annually reported in Japan, and death occurs in 30%-60% of them), the diagnosis of tetanus is given little attention. A portal of entry was not found in 7%-17% of patients [1]. Clinical tetanus comprises four symptomatic types: generalized, local, cephalic, and neonatal tetanus [1]. Cephalic tetanus presents with cranial nerve palsy, particularly of the facial nerve, and is always scored as severe or very severe, since approximately two thirds of cases progress to generalized tetanus [1-4]. The incidence of cephalic tetanus ranges from 0.9% to 3.0% [2-4]. Patients often have a history of trauma [2,5,6], tooth extraction [7], or chronic tympanitis [3], presenting with incomplete Bell's palsy [5]. When this patient was first seen, she had an atypical hemipalsy of Bell's palsy. Her body temperature was normal. There were no wounds and no inflammatory focus, yet she had a left-lower-quarter facial tonic spasm. We considered oro-facio-mandibular dystonia due to a basal ganglia disorder, painful tonic seizure due to multiple sclerosis, and acute cranial-type stiffman syndrome [8]. There were no remarkable changes in basal ganglia on MRI or in the laboratory data, and the patient showed progressing generalized seizure without disturbance of consciousness, trismus, and dyspnea, as are typical in tetanus. The serum antitetanus immune globulin level on admission (<0.01 IU/mL) showed that the patient had no immunity against tetanus. Although the intensive care was lifesaving, the patient repeatedly denied any trauma within the past month; hence, there was a delay in diagnosing cephalic tetanus. In conclusion, when a patient presents with facial palsy in the absence of any history of trauma, a differential diagnosis of cephalic tetanus should be ruled out. We thank M. Ohara for reading the manuscript." @default.
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• W4230344836 date "1996-08-01" @default.
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• W4230344836 title "Cephalic Tetanus in a Nontraumatized Patient with Left Facial Palsy" @default.
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