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Images in Neurology
April 2011

Cranial Nerve VII Palsy as the First Sign of Cephalic Tetanus After an Earthquake

Author Affiliations

Author Affiliations: Department of Internal Medicine, National Naval Medical Center (Dr Gleeson), and Department of Neurology, National Naval Medical Center (Dr Etienne), Bethesda, Maryland.

Arch Neurol. 2011;68(4):536-537. doi:10.1001/archneurol.2011.55

A 29-year-old man sustained right-sided periorbital and frontal scalp abrasions caused by falling cement during the January 12, 2010, earthquake in Haiti. Twelve days later, he developed weakness of the right side of his face. He received local wound care and intravenous cefazolin sodium. On physical examination, he had a subconjunctival hemorrhage and an isolated right-sided cranial nerve VII palsy. He reported pain in his jaw; however, he had a normal range of motion. Computed tomography of the head revealed no skull or jaw fractures. One day after discharge from the hospital, he noted difficulty in opening his mouth and new numbness on the right side of his face. His symptoms worsened over 7 days. He was evaluated at another hospital, where a gastric feeding tube was placed because of his inability to open his mouth. On readmission to the hospital, a new cranial nerve V palsy, a new subtle cranial nerve VI palsy, and a persistent cranial nerve VII palsy were noted (all right-sided) in addition to trismus and neck rigidity. His voice was soft; he experienced frequent left-sided facial spasms (Figure 1). Tetanus toxoid, tetanus immune globulin (3000 U intramuscularly), and intravenous metronidazole phosphate were given. A second computed tomograph of the head showed no abnormalities. Results of cerebrospinal fluid testing were normal. The patient underwent surgical exploration and debridement of his wounds that revealed no persistent infection. He never required intubation. Over 16 days, his trismus, neck rigidity, and left-sided facial spasms resolved, and he was able to drink a liquid diet through a straw. A residual cranial nerve VII palsy persisted 21 days after hospital discharge (Figure 2).