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Tuberculous ‘lock jaw’ Shyam Yadav, Karan Madan Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India Correspondence to Dr Karan Madan, [email protected] Accepted 28 June 2015
To cite: Yadav S, Madan K. BMJ Case Rep Published online: [ please include Day Month Year] doi:10.1136/ bcr-2015-211183
DESCRIPTION A 23-year-old woman presented with history of facial swelling (right side) and inability to open her mouth (figure 1A) for 2 weeks. Physical examination was normal. Tuberculin skin test performed at another centre prior to referral to our facility had demonstrated 25 mm induration. CT scan (neck and thorax) was performed, which demonstrated bulky right side masseter muscle with necrotic areas (figure 1B) and necrotic appearing mediastinal lymphadenopathy. Ultrasound-guided aspirate from masseter muscle yielded thick cheesy pus. Staining for acid-fast bacilli was positive and culture grew Mycobacterium tuberculosis. Facial swelling and jaw opening recovered within 2 months of four drug antituberculous treatment. Tuberculosis (TB) of the masseter muscle is an unusual cause of trismus (lock jaw). The musculoskeletal system is involved in nearly 3% of cases of extrapulmonary TB, usually presenting as spondylitis, osteomyelitis or arthritis. Skeletal muscle involvement in TB is rare. Primary tuberculous myositis may mimic malignancy. Usually, a single muscle group is involved, and thigh muscle involvement is most commonly reported. Muscles are involved primarily by spread from contiguous sites followed by haematogenous route and rarely by direct inoculation. Paraspinal and chest wall muscles are the commonest sites for contiguous spread. Primary tuberculous involvement of the masseter muscle is
unusual.1 TB of the masseter muscle is an unusual cause of trismus and sometimes the presentation may include a submasseteric abscess rather than primary muscle involvement.2 TB should be considered in the differentials of muscular disease in endemic settings.
Learning points ▸ Skeletal muscle involvement is an unusual presentation of musculoskeletal tuberculosis. ▸ Tuberculosis can, rarely, involve the masseter muscle and present as trismus.
Contributors SY contributed to manuscript preparation. KM contributed to patient management and manuscript preparation. Competing interests None declared. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2
Andrade NN, Mhatre TS. Orofacial tuberculosis—a 16-year experience with 46 cases. J Oral Maxillofac Surg 2012;70:e12–22. Mascarenhas S, Tuffin J, Hassan I. Tuberculous submasseteric abscess: case report. Br J Oral Maxillofac Surg 2009;47:566–8.
Figure 1 (A) Clinical image demonstrating swelling over the right jaw and inability to open the mouth. (B) CT demonstrating hypodense necrotic appearing areas within the right masseter muscle.
Yadav S, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-211183
1
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Copyright 2015 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
2
Yadav S, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-211183
Tuberculous ‘lock jaw’ Shyam Yadav, Karan Madan Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India Correspondence to Dr Karan Madan, [email protected] Accepted 28 June 2015
To cite: Yadav S, Madan K. BMJ Case Rep Published online: [ please include Day Month Year] doi:10.1136/ bcr-2015-211183
DESCRIPTION A 23-year-old woman presented with history of facial swelling (right side) and inability to open her mouth (figure 1A) for 2 weeks. Physical examination was normal. Tuberculin skin test performed at another centre prior to referral to our facility had demonstrated 25 mm induration. CT scan (neck and thorax) was performed, which demonstrated bulky right side masseter muscle with necrotic areas (figure 1B) and necrotic appearing mediastinal lymphadenopathy. Ultrasound-guided aspirate from masseter muscle yielded thick cheesy pus. Staining for acid-fast bacilli was positive and culture grew Mycobacterium tuberculosis. Facial swelling and jaw opening recovered within 2 months of four drug antituberculous treatment. Tuberculosis (TB) of the masseter muscle is an unusual cause of trismus (lock jaw). The musculoskeletal system is involved in nearly 3% of cases of extrapulmonary TB, usually presenting as spondylitis, osteomyelitis or arthritis. Skeletal muscle involvement in TB is rare. Primary tuberculous myositis may mimic malignancy. Usually, a single muscle group is involved, and thigh muscle involvement is most commonly reported. Muscles are involved primarily by spread from contiguous sites followed by haematogenous route and rarely by direct inoculation. Paraspinal and chest wall muscles are the commonest sites for contiguous spread. Primary tuberculous involvement of the masseter muscle is
unusual.1 TB of the masseter muscle is an unusual cause of trismus and sometimes the presentation may include a submasseteric abscess rather than primary muscle involvement.2 TB should be considered in the differentials of muscular disease in endemic settings.
Learning points ▸ Skeletal muscle involvement is an unusual presentation of musculoskeletal tuberculosis. ▸ Tuberculosis can, rarely, involve the masseter muscle and present as trismus.
Contributors SY contributed to manuscript preparation. KM contributed to patient management and manuscript preparation. Competing interests None declared. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2
Andrade NN, Mhatre TS. Orofacial tuberculosis—a 16-year experience with 46 cases. J Oral Maxillofac Surg 2012;70:e12–22. Mascarenhas S, Tuffin J, Hassan I. Tuberculous submasseteric abscess: case report. Br J Oral Maxillofac Surg 2009;47:566–8.
Figure 1 (A) Clinical image demonstrating swelling over the right jaw and inability to open the mouth. (B) CT demonstrating hypodense necrotic appearing areas within the right masseter muscle.
Yadav S, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-211183
1
Images in…
Copyright 2015 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
2
Yadav S, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-211183
