Trismus caused by cephalic tetanus Case report
Spyridon ATHANASIOU, Konstantinos MOUROUZIS, Andreas MARKETOS, Sofia TSAOUSI, Moisis LELEKIS, Giorgos RALLIS
Department of Oral and Maxillofacial Surgery (Director and Head: Dr G. Rallis) and Department of Internal Medicine (Director and Head: M. Lelekis), General Hospital of Attica “ΚΑΤ”, Athens
Hellenic Archives of Oral & Maxillofacial Surgery (2016) 1, 21-26
SUMMARY: Trismus is defined as the inability to open the mouth. Several diseases and conditions are included in its differential diagnosis, such as infections, trauma, neo- plasms, temporomandibular joint disorders. Cephalic tetanus is a rare form of tetanus that is limited to the area of the head and neck; trismus can be the first symp- tom of the disease.
Case presentation: A 77-year-old male patient with a non- contributory medical history, presented with a gradually deteriorating ability to open his mouth. He underwent a full set of tests, and there were no pathological findings. The tongue depressor test, in which the instrument touches the nasopharyngeal mucosa, was positive for tetanus, as in this case it caused trismus instead of vom- iting reflex. The patient was treated with metronidazole intravenously and received active and passive immuniza- tion against clostridium tetani. His clinical condition im- proved and he was discharged after 10 days.
Conclusion: Cephalic tetanus is a rare but potentially life- threatening cause of trismus. Physicians should maintain a high index of suspicion in cases of trismus, in order to make an early diagnosis of the disease, provide effective treatment in a timely manner and prevent complications.
KEY WORDS: trismus, tetanus, cephalic tetanus, clostrid- ium tetani
REFERENCES
Agarwal AK, Mudgerikar S, Sangla KS, Gogna A, Jain A: Facial palsy of uncommon aetiology (cephalic tetanus). J Assoc Physicians India. 43(3):229-30, 1995
Agrawal J, Shenai PK, Chatra L, Kumar PY: Evaluation of normal range of mouth opening using three finger index: South India perspective study. Indian J Dent Res. 26(4): 361-5, 2015
Alhaji MA, Abdulhafiz U, Atuanya CI, Bukar FL: Cephalic Tetanus: A Case Report. Case Reports in Infectious Diseases Volume 2011 (2011), Article ID 780209
Apte NM, Karnad DR: Short report: the spatula test: a simple bedside test to diagnose tetanus. Am J Trop Med Hyg. 53(4): 386-7, 1995
Chebel S, Letaief L, Boughammoura-Bouatay A, Dachraoui F, Ouanes I, Ouanes-Besbes L, Abroug F, Frih-Ayed M: Multiple cranial nerve involvement: consider the diagnosis of cephalic tetanus. A case report and review of the literature. Rev Neurol (Paris) 166(11): 948-50. 2010
De Paz A, Izquierdo M, Redondo LM, Verrier A: Cephalic tetanus fol- lowing minor facial abrasions: report of a case. J Oral Maxillofac Surg. 59(7): 800-1, 2001
Dhanrajani PJ, Jonaidel O: Trismus: Aetiology, Differential Diagnosis and Treatment. Dent Update 29: 88–94, 2002
Dong Hyuk Seo, Dae Kyung Cho, Hee Chung Kwon, Tae Uk Kim,: A Case of Cephalic Tetanus with Unilateral Ptosis and Facial Palsy. Ann Rehabil Med 36(1), 2012
Felter RA, Zinns LE: Cephalic Tetanus in an Immunized Teenager: An Unusual Case Report. Pediatr Emerg Care. 31(7): 511-3, 2015
Fusetti S, Ghirotto C, Ferronato G: A case of cephalic tetanus in a de- veloped country. Int J Immunopathol Pharmacol. 26(1): 273-7, 2013
Gibson K, Bonaventure Uwineza J, Kiviri W, Parlow J: Tetanus in de- veloping countries: a case series and review. Can J Anaesth. 56(4): 307-15, 2009
Hassani R, Herkani A, Nouri H, Boukind S, Tassi N, Raji A.: Cephalic tetanus revealed by peripheral facial palsy. Rev Stomatol Chir Maxillofac. 112(5): 313-5, 2011
Jagoda A, Riggio S, Burguieres T: Cephalic tetanus: a case report and review of the literature. Am J Emerg Med. 6(2): 128-30, 1988
Nakazawa K, Kanda F, Ishihara H, Matsushita T, Chihara K: A case of cephalic tetanus presenting with opisthotonus. Rinsho Shinkeigaku. 41(4-5): 187-90. 2001
Kanazawa M, Ishiguro H, Onodera O, Yoshikawa K, Koide T, Arai A et al: Two cases of generalized tetanus presenting with dysphagia as an initial symptom. No To Shinkei. 55(11): 973-6, 2003
Kara CO, Cetin CB, Yalçin N: Cephalic tetanus as a result of rooster pecking: an unusual case. Scand J Infect Dis. 34(1): 64-6, 2002
Kwon JC, Park Y, Han ZA, Song JE, Park HS: Trismus in cephalic tetanus from a foot injury. Korean J Intern Med. 28(1): 121, 2013
Luyk NH, Steinberg B: Aetiology and diagnosis of clinically evident jaw trismus. Aust Dent J. 35(6): 523-9, 1990
Paterson AW, Ryan W, Rao-Mudigonda VV: Trismus: or is it tetanus? A report of a case. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 101(4):37-41, 2006
Rauch A, Droz S, Zimmerli S, Leib SL: Dysphagia in elderly women: consider tetanus. Infection. 34(1): 35-8, 2006
Salgueiro MI, Stevens MR: Management of the irradiated patient, in: Current therapy in oral and maxillofacial surgery 1st edition 2011, pp 220-221
Tahery J, Morris DP, Birzgalis AR: Tetanus: the 'forgotten disease'. A rare cause of dysphagia and trismus. J Laryngol Otol. 118(12): 974-6, 2004 Toydemir RM, Chen H, Proud VK, Martin R, van Bokhoven H, Hamel BC, et al: Trismus-pseudocamptodactyly syndrome is caused by recurrent mutation of MYH8. Am J Med Genet A. 140(22):2387- 93, 2006
Tveterås K, Kristensen S: The aetiology and pathogenesis of trismus. Clin Otolaryngol Allied Sci. 11(5): 383-7, 1986
Zachariades N, Koumoura F, Komis C: Cephalic tetanus: report of case. Br J Oral Maxillofac Surg. 41(5): 338-9, 2003
Department of Oral and Maxillofacial Surgery (Director and Head: Dr G. Rallis) and Department of Internal Medicine (Director and Head: M. Lelekis), General Hospital of Attica “ΚΑΤ”, Athens
Hellenic Archives of Oral & Maxillofacial Surgery (2016) 1, 21-26
SUMMARY: Trismus is defined as the inability to open the mouth. Several diseases and conditions are included in its differential diagnosis, such as infections, trauma, neo- plasms, temporomandibular joint disorders. Cephalic tetanus is a rare form of tetanus that is limited to the area of the head and neck; trismus can be the first symp- tom of the disease.
Case presentation: A 77-year-old male patient with a non- contributory medical history, presented with a gradually deteriorating ability to open his mouth. He underwent a full set of tests, and there were no pathological findings. The tongue depressor test, in which the instrument touches the nasopharyngeal mucosa, was positive for tetanus, as in this case it caused trismus instead of vom- iting reflex. The patient was treated with metronidazole intravenously and received active and passive immuniza- tion against clostridium tetani. His clinical condition im- proved and he was discharged after 10 days.
Conclusion: Cephalic tetanus is a rare but potentially life- threatening cause of trismus. Physicians should maintain a high index of suspicion in cases of trismus, in order to make an early diagnosis of the disease, provide effective treatment in a timely manner and prevent complications.
KEY WORDS: trismus, tetanus, cephalic tetanus, clostrid- ium tetani
REFERENCES
Agarwal AK, Mudgerikar S, Sangla KS, Gogna A, Jain A: Facial palsy of uncommon aetiology (cephalic tetanus). J Assoc Physicians India. 43(3):229-30, 1995
Agrawal J, Shenai PK, Chatra L, Kumar PY: Evaluation of normal range of mouth opening using three finger index: South India perspective study. Indian J Dent Res. 26(4): 361-5, 2015
Alhaji MA, Abdulhafiz U, Atuanya CI, Bukar FL: Cephalic Tetanus: A Case Report. Case Reports in Infectious Diseases Volume 2011 (2011), Article ID 780209
Apte NM, Karnad DR: Short report: the spatula test: a simple bedside test to diagnose tetanus. Am J Trop Med Hyg. 53(4): 386-7, 1995
Chebel S, Letaief L, Boughammoura-Bouatay A, Dachraoui F, Ouanes I, Ouanes-Besbes L, Abroug F, Frih-Ayed M: Multiple cranial nerve involvement: consider the diagnosis of cephalic tetanus. A case report and review of the literature. Rev Neurol (Paris) 166(11): 948-50. 2010
De Paz A, Izquierdo M, Redondo LM, Verrier A: Cephalic tetanus fol- lowing minor facial abrasions: report of a case. J Oral Maxillofac Surg. 59(7): 800-1, 2001
Dhanrajani PJ, Jonaidel O: Trismus: Aetiology, Differential Diagnosis and Treatment. Dent Update 29: 88–94, 2002
Dong Hyuk Seo, Dae Kyung Cho, Hee Chung Kwon, Tae Uk Kim,: A Case of Cephalic Tetanus with Unilateral Ptosis and Facial Palsy. Ann Rehabil Med 36(1), 2012
Felter RA, Zinns LE: Cephalic Tetanus in an Immunized Teenager: An Unusual Case Report. Pediatr Emerg Care. 31(7): 511-3, 2015
Fusetti S, Ghirotto C, Ferronato G: A case of cephalic tetanus in a de- veloped country. Int J Immunopathol Pharmacol. 26(1): 273-7, 2013
Gibson K, Bonaventure Uwineza J, Kiviri W, Parlow J: Tetanus in de- veloping countries: a case series and review. Can J Anaesth. 56(4): 307-15, 2009
Hassani R, Herkani A, Nouri H, Boukind S, Tassi N, Raji A.: Cephalic tetanus revealed by peripheral facial palsy. Rev Stomatol Chir Maxillofac. 112(5): 313-5, 2011
Jagoda A, Riggio S, Burguieres T: Cephalic tetanus: a case report and review of the literature. Am J Emerg Med. 6(2): 128-30, 1988
Nakazawa K, Kanda F, Ishihara H, Matsushita T, Chihara K: A case of cephalic tetanus presenting with opisthotonus. Rinsho Shinkeigaku. 41(4-5): 187-90. 2001
Kanazawa M, Ishiguro H, Onodera O, Yoshikawa K, Koide T, Arai A et al: Two cases of generalized tetanus presenting with dysphagia as an initial symptom. No To Shinkei. 55(11): 973-6, 2003
Kara CO, Cetin CB, Yalçin N: Cephalic tetanus as a result of rooster pecking: an unusual case. Scand J Infect Dis. 34(1): 64-6, 2002
Kwon JC, Park Y, Han ZA, Song JE, Park HS: Trismus in cephalic tetanus from a foot injury. Korean J Intern Med. 28(1): 121, 2013
Luyk NH, Steinberg B: Aetiology and diagnosis of clinically evident jaw trismus. Aust Dent J. 35(6): 523-9, 1990
Paterson AW, Ryan W, Rao-Mudigonda VV: Trismus: or is it tetanus? A report of a case. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 101(4):37-41, 2006
Rauch A, Droz S, Zimmerli S, Leib SL: Dysphagia in elderly women: consider tetanus. Infection. 34(1): 35-8, 2006
Salgueiro MI, Stevens MR: Management of the irradiated patient, in: Current therapy in oral and maxillofacial surgery 1st edition 2011, pp 220-221
Tahery J, Morris DP, Birzgalis AR: Tetanus: the 'forgotten disease'. A rare cause of dysphagia and trismus. J Laryngol Otol. 118(12): 974-6, 2004 Toydemir RM, Chen H, Proud VK, Martin R, van Bokhoven H, Hamel BC, et al: Trismus-pseudocamptodactyly syndrome is caused by recurrent mutation of MYH8. Am J Med Genet A. 140(22):2387- 93, 2006
Tveterås K, Kristensen S: The aetiology and pathogenesis of trismus. Clin Otolaryngol Allied Sci. 11(5): 383-7, 1986
Zachariades N, Koumoura F, Komis C: Cephalic tetanus: report of case. Br J Oral Maxillofac Surg. 41(5): 338-9, 2003
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