A 3-year-old male, Tunisian, seronegative for human immunodeficiency virus, who at 26 years of age experienced an episode of otalgia, followed by Bell's palsy two days later.
Otorhinolaryngological evaluation and serology for herpes simplex, herpes zoster, adenovirus, cytomegalovirus, coxsackie virus, enterovirus, influenza, lymphocytic choriomeningitis, herpes virus
A high resolution CT scan of the temporal bone and mastoid and a magnetic resonance imaging (MRI) of the temporomandibular joint were repeatedly performed, with no pathological findings.
In particular, no anomalies of the deep auditory canal, vestibulocochlear or labyrinth were detected.
In addition, a cervical planigraphy was normal.
Facial nerve conduction studies and recording of the oral orbicular muscle revealed a muscular action potential of only 741 μΥ upon stimulation from the left side.
The evaluation showed a 2 mm lagophthalmos but during a forced closure of eyelids, the cornea was covered and a temporary tarsorrhaphy was proposed.
A cervical ultrasound showed only one thyroid adenoma, which was visualized as a cold lesion on the scintigram.
A cervical CT scan showed moderate growth of lymph nodes in the left carotid triangle, in infraclavicular, submandibular, submental and along the internal jugular veins.
In the following years, Bell's palsy improved slightly but pain remained oscillating without changing its maximum intensity, despite extensive analgesia including non-steroidal analgesics, tramadol, carbamazepine, neural therapy and acupuncture.
At the age of 33 years, the patient consulted again in the Department of Otolaryngology.
This time he reported an intensification of Bell's palsy and extreme fatigue after performing exercises at work.
In the new clinical examination, adenopathies in the neck and retromandibular gland were observed, resulting in a stylohyoid syndrome.
Neurological examination revealed pain at the origin of the masseteric muscle, enlarged lymph nodes in the left carotid and submandibular triangle, and Bell's palsy.
He had no hemogram at all.
Cervical MRI showed no major pathological findings.
We hypothesized atypical facial pain, neuralgia, or migraine, increasing gabapentin dose to 900 mg/ day without a favorable response.
Multi-subsidy serology against Echi, lumbar puncture and lymph node biopsy were proposed, but the patient initially only consented with the measurement of antibodies against Toxoplasma gondii, T. canis, Taenia solium,
Unexpectedly, the ELISA test for T. canis antibodies showed a titer of 70 UAK (normal: < 25 UAK).
In addition, Westernblot for T. canis ES antigen was positive in serum.
When toxocarosis was diagnosed, albendazole therapy was performed, 15 mg/kg of weight (800 mg/d) for three weeks, a scheme that was repeated twice later.
At the end of the first cycle of albendazole, the patient reported temporary cessation of pain for the first time in the last six years.
In addition, non-steroidal analgesics were again effective.
After finishing the cure with albenda-zol, amoxicillin/clavulanic acid was prescribed to avoid overinfection of behavioral disorders by larvae.
No infectious focus of T. canis was detected in the lung or liver.
In the follow-up after seven or eight months of albendazole therapy, the clinical manifestations had not changed mostly but the antibody titer against T. canis decreased to 25 UAK.
On this occasion, the patient accepted the lumbar puncture procedure but his rejection to lymph node biopsy persisted.
The cytochemical analysis of CSF, having made the antiparasitic therapy, was normal, except for the positivity of the ES antigen of T. canis by Westernblot.
CRL was not detected, nor was Th2 deviation detected in supernatant2, and there was a negative PCR for T. canis.
