Article Text
Statistics from Altmetric.com
BACKGROUND
A 76-year-old right handed woman awoke with sudden onset of difficulty with swallowing, slurred speech and left-sided facial weakness and numbness. She had multiple vascular risk factors: hypertension, hypercholesterolaemia, impaired glucose tolerance and a 50 pack-year smoking history. Twelve days before presentation she had developed right-sided facial weakness. Ten days before presentation she had sustained a right supraorbital laceration which required suturing after falling on to pavement (figure 1). A CT scan of the head at the time of injury was normal (figure 2). On examination, there was left-sided upper motor neurone facial palsy and right lower motor neurone facial palsy, with dysarthria but no dysphasia, diminished sensation over the left maxillary and mandibular areas, and normal limb examination. Given her constellation of signs, we considered the possibility of brainstem stroke and recent right Bell's palsy.
Star-shaped right supraorbital laceration sustained 10 days before presentation during a road traffic accident. This is the wound from which Clostridium tetani was eventually cultured. This photograph was taken after the wound was further debrided and post decannulation, as evidenced by her tracheostomy scar.
Axial CT scan of head post injury shows a large extracranial soft tissue swelling overlying the frontal bones, particularly on the right side and extending inferiorly into the right periorbital region. Tiny radiopaque densities within this extracranial soft tissue swelling raise the possibility of foreign bodies. The ventricular system and basal cisterns are normal.
CT scan of head and CT angiogram showed a large right supraorbital haematoma, but no acute stroke (figure 3 …
Footnotes
-
Acknowledgements The National Hospital for Neurology and Neurosurgery.
-
Contributors AD: Helped manage the case. initiated, drafted and revised the paper. She is the second guarantor. CW: revised the paper. She edited the images. DD: helped manage the case. Revised the paper. DK: revised the paper. He is the senior guarantor.
-
Competing interests None.
-
Patient consent Obtained.
-
Provenance and peer review Not commissioned; externally peer reviewed. This paper was reviewed by William Whiteley, Edinburgh.
Linked Articles
- Editors' choice
Read the full text or download the PDF:
Other content recommended for you
- Cephalic tetanus as a differential diagnosis of facial nerve palsy
- Clostridial neurotoxins
- Guillain-Barré syndrome
- Making an objective diagnosis of tetanus—utility of a simple neurophysiological test
- Brainstem encephalitis and acute polyneuropathy associated with hepatitis E infection
- A rare case of Miller Fisher variant of Guillain-Barré Syndrome (GBS) induced by a checkpoint inhibitor
- JUST A GRAZE?
- Return of the old guard: a case of tetanus in an unvaccinated patient
- Guillain-Barré syndrome mimicking botulism in early disease course
- Rocuronium for control of muscle spasms in a tetanus patient with chronic methamphetamine use disorder