Forum for Clinical and Surgical Oral Pathology

Case BBOPF 08-6

Dr. James Cade (Manchester, Tennessee, USA) invites your comments reagarding one of his cases. Please send your comments in the window located below the images. This case will be posted from September 12 to September 19, 2008. A summary of the responses will be posted in BBOP.

Clinical History

The patient is a 38 year old white female with an ongoing undiagnosed condition for 2 years. She saw many doctors (dentists and physicians) and they did not come to a diagnosis. Her condition may be a combination of different disorders. She was diagnosed with fibromyalgia about 7 years ago but did not have any treatments because it wasn't severe.

Her current condition symptoms started 2 years ago simulating a stroke. She had nausea, left limbs got real heavy and went numb and then her left jaw “dropped or drooped”. She was taken to the hospital. After four days in the hospital, she was released with no signs of paralysis and no confirmation of a stroke. The physicians could not make a diagnosis. CT scans and MRI's showed nothing.

Four months later, the same symptoms returned. After more negative MRI's and CT scans, no more progress was made in making a diagnosis. Three months later she had another episode with the same results. Two months later she had another episode but mainly it was just her jaw pulling down or drooping with pain this time. One of the most severe episodes she had was on Christmas Eve. Her husband put on some cologne that she had never had a reaction to before and within seconds after spraying it, her jaw “dropped” and then almost every muscle in her body contracted. This incident lasted all night and went to the ER until three in the morning. The physicians found nothing physically wrong. After a month or two the episodes would happen more frequently, but most of the time weren't as severe as the first ones.

Later while steaming the carpet with ammonia, she breathed it and her jaw instantly dropped and started hurting (the patient steams carpets for a living). That led her physician and us to believe that it all was chemically related or smell related. Now, for the last year, she has seen 5 different neurologists, a chemical sensitivity, allergy physician, one ENT physician, two neurology/ENT physicians, a TMJ/pain dentist, a chiropractor and a homeopathic doctor. None of these have helped. Over this time her symptoms changed to where the episodes are not as severe but severe enough to make her quit driving and working.

Now her episodes start out as puffiness in her left cheek/jaw area. Then the left side of her mouth will drop or droop and it feels like her jaw muscles will tighten up with extreme pain. Sometimes the more severe episodes manifest with her right eyelid closing with the appearance of someone who is severely drunk. Sometimes massaging the jaw area will stop the drooping but when the massaging stops it returns. These episodes are now usually happening several times daily and seem to disappear on their own. Sometimes they'll last only a couple of minutes and then sometimes they'll last then disappear all day

The triggers are what may be throwing all the doctors off, but the triggers have changed also. The first strong pattern of triggers were odors such as perfume, cologne, gasoline, air fresheners, strong flowers, bleach, garlic bread baking in the oven, bacon frying, auto exhaust and other various strong odors. Now, odors still do but wind, barometric pressure changes and simply bending over can cause her signs and symptoms too.

Her physicians have suggested that these episodes were caused by seizures, hemiplegic migraines, epilepsy and MS. Other theories including trigeminal neuralgia or hemifacial spasm through testing all of these have shown no results. Bottom line triggers of various sorts cause the episodes, but they are very unpredictable as to type.

When I saw her she was having an episode and the description given above by her husband was very accurate. I thought of myasthenia gravis, but when the patient talks more and eats, the symptoms tend to go away and her lip begins to look more normal. I find it interesting that her right eye closes when the left side is affected by drooping of her lip. During an episode her right eye shuts, but she can blink her left eye.

The patient gave me permission to post this on the BBOP and IBBOM list serve with her unconcealed picture in the hopes someone has an idea for diagnosis.

Thanks,

James Cade, D.D.S.
Tennesse. USA

Images

[Click for a larger image] Figure 1

[Click for a larger image] Figure 2

[Click for a larger image] Figure 3

Case prepared by Dr. Alfredo Aguirre (BBOP Manager) and Daniel Emmer (Web Administrator, University at Buffalo School of Dental Medicine).