Cephalic tetanus manifesting as isolated facial nerve palsy- a case report from rural Armenia.

Cephalic tetanus is a rare clinical form of tetanus, clinically characterized by trismus and cranial nerve palsy involving one or more cranial nerves, facial nerve being the most common. We report a case of cephalic tetanus with left-sided lower motor facial nerve palsy in a 66-year-old non-immunized patient after an untreated laceration injury. The patient had dysphagia, spasm of the muscles of mastication, asymmetry of the left side of the face, cough, shortness of breath, and stiffness of neck muscles. The presentation was unique given that the facial nerve palsy appeared prior to the occurrence of trismus, which misled the initial diagnosis towards Bell's palsy. He was successfully treated with tetanus antitoxin without any adverse events. Although widespread use of tetanus vaccine has led to a dramatic decline in this fatal disease, sporadic disease occurrence is still possible, particularly in individuals without up-to-date vaccinations. In this case report we illustrate the importance of early recognition of cephalic tetanus prior to the development of the full clinical picture. The early initiation of therapy is the key to recovery from this deadly disease. Physicians are encouraged to include cephalic tetanus as a cause of facial nerve palsy in their differential. In particular, paying attention to cases manifesting early after head or neck injury.

Erythema Nodosum: An Unusual Clinical Manifestation of Oropharyngeal Tularemia.

Tularemia is a zoonotic infection caused by Francisella tularensis. Oropharyngeal tularemia, one of the several clinical forms of tularemia identified, is typically characterized by fever, sore throat, cervical buboes, and rarely, cutaneous lesions. Here we describe an uncommon clinical manifestation of oropharyngeal tularemia with erythema nodosum, an inflammatory condition that causes tender nodules to form on the lower legs. A 45-year-old woman with fever, sore throat, unilateral cervical buboes, and erythema nodosum on both legs was diagnosed with oropharyngeal tularemia based on clinical manifestations and positive latex agglutination testing. We prescribed a 14-day course of intramuscular streptomycin, which resulted in the complete recovery of the patient. It is unusual for tularemia to manifest with erythema nodosum as a primary symptom, particularly one that persists throughout the illness. Although the cause of erythema nodosum is unknown in nearly half of cases, it is important to identify or exclude possible infectious causes of this condition, including tuberculosis, Valley fever, cat scratch disease, and, as illustrated in the case described herein, tularemia.