A 33-year-old woman comes to the office with severe bilateral facial pain for the past several days. She reports sharp, shooting pain that is confined to her cheeks and jaw, lasts several seconds, and occurs 10-20 times a day. The pain is sometimes triggered by a cold breeze, brushing of her teeth, or chewing. The patient has been taking ibuprofen for the pain without much relief. She has never experienced this condition before, but 6 months ago she had numbness of her right hand that lasted about 2 weeks. Four weeks ago, she was treated for acute sinusitis. The patient is a primary school teacher and does not use tobacco, alcohol, or illicit drugs. Her temperature is 36.7 C (98 F), blood pressure is 118/82 mm Hg, pulse is 72/min, and respirations are 14/min. On physical examination, a similar pain is elicited by lightly touching the patient's cheeks. Otherwise, neurologic examination demonstrates no focal deficits. Which of the following is the most likely cause of this patient's symptoms?

Question

A 33-year-old woman comes to the office with severe bilateral facial pain for the past several days.  She reports sharp, shooting pain that is confined to her cheeks and jaw, lasts several seconds, and occurs 10-20 times a day.  The pain is sometimes triggered by a cold breeze, brushing of her teeth, or chewing.  The patient has been taking ibuprofen for the pain without much relief.  She has never experienced this condition before, but 6 months ago she had numbness of her right hand that lasted about 2 weeks.  Four weeks ago, she was treated for acute sinusitis.  The patient is a primary school teacher and does not use tobacco, alcohol, or illicit drugs.  Her temperature is 36.7 C (98 F), blood pressure is 118/82 mm Hg, pulse is 72/min, and respirations are 14/min.  On physical examination, a similar pain is elicited by lightly touching the patient's cheeks.  Otherwise, neurologic examination demonstrates no focal deficits.  Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

This patient has trigeminal neuralgia, a disorder characterized by recurrent and sudden-onset severe, stabbing pain along the V2 (maxillary) and V3 (mandibular) branches of the trigeminal nerve, which usually occurs unilaterally. The episodes last for a few seconds to minutes and can be triggered by minor stimuli (eg, touch, wind, chewing). trigeminal nerve Multiple sclerosis (MS), an autoimmune demyelinating central nervous system disorder, is one of the few conditions that may present with trigeminal neuralgia bilaterally. This occurs due to demyelination of the trigeminal nerve axon or the nerve root, which leads to improper signaling of the nerve and paroxysms of severe pain. This patient's episode of right hand numbness that lasted 2 weeks and spontaneously improved was likely her first symptom of MS. (Choice A) Basilar migraines occur due to cerebral vasospasm involving the brainstem. Patients typically have basilar aura symptoms (eg, vertigo, dysarthria, tinnitus, diplopia) without motor weakness, followed by a migraine-type headache. Patients would likely not have bilateral trigeminal neuralgia or numbness of an arm lasting several weeks. (Choice C) Herpes zoster is caused by nerve inflammation from viral reactivation, leading to neuritis followed by a dermatomal vesicular rash. When the trigeminal nerve is involved, it is usually the V1 branch (herpes zoster ophthalmicus), which can lead to blindness. In a healthy patient, herpes zoster usually involves one dermatome and is unlikely to present bilaterally. (Choice D) Infection of the medial face, sinuses (ethmoidal or sphenoidal), or teeth may spread through the valveless facial venous system into the cavernous sinus, resulting in cavernous sinus thrombosis. Patients typically present with headache, fever, proptosis, and ipsilateral deficits in cranial nerves III, IV, VI, and V (ophthalmic and maxillary branches). (Choice E) Viral infection (eg, enteroviruses, herpes simplex virus) of the meninges causes aseptic meningitis, which usually presents with a flu-like illness and meningeal symptoms/signs (eg, headache, fever, nuchal rigidity). Educational objective: Trigeminal neuralgia is characterized by recurrent and sudden-onset severe, stabbing pain along the V2 (maxillary) and V3 (mandibular) branches of the trigeminal nerve. Multiple sclerosis should be suspected when trigeminal neuralgia presents bilaterally. References: Trigeminal neuralgia and pain related to multiple sclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/19171430) Association between trigeminal neuralgia and multiple sclerosis: role of magnetic resonance imaging. (http://www.ncbi.nlm.nih.gov/pubmed/7673952)

A 33-Year-Old Woman Comes to the Office with Severe Bilateral