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Cerebrovascular Disease

Multiple Facial Ulcers Following a Stroke

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.

1 Credit CME

JAMA Neurology

Published Online: July 19, 2021

JAMA Neurology Clinical Challenge

Article Information and Disclosures

Beke Esther Linnemann¹;

Alexander Neumann, MD²;

Iakov Shimanovich, MD¹

Author Affiliations

¹Department of Dermatology, University of Lübeck, Lübeck, Germany
²Department of Neuroradiology, University of Lübeck, Lübeck, Germany

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A 66-year-old man presented with multiple progressive ulcers on the right side of his face that had developed over the past 3 months (Figure, A). He had also experienced a burning sensation on the right side of his face, but denied headache, shoulder, or jaw pain and visual disturbance. Neurological examination revealed hypoesthesia of the right side of the face, while cold-warm sensation and motor function were intact. The erythrocyte sedimentation rate was 82 mm per hour (normal value, less than 15 mm per hour) and the serum C–reactive protein concentration was 107 mg/L (normal value, less than 5 mg/L). Chest radiography showed bilateral perihilar infiltrates consistent with pneumonia. About 2 weeks before the ulcerations developed, the patient had been admitted to the hospital for unstable angina, and coronary angiography was performed. Immediately after the angiography, the patient developed left-sided hemiplegia and hemianopsia. Magnetic resonance imaging of the brain revealed an extensive ischemic posterior circulation stroke involving the right occipital lobe, lower cerebellar peduncle, and pontomedullary boundary (Figure, B).

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C. Trigeminal trophic syndrome

As the patient was unaware of the self-inflicted nature of the injuries, he was advised to wear cotton gloves to prevent further skin damage due to unintentional scratching, and the ulcers were treated with daily occlusive antiseptic dressings. All lesions healed almost completely within 7 weeks, while hypoesthesia and paresthesia of the right face also resolved. The pneumonia responded to antibiotic therapy, while the erythrocyte sedimentation rate and C-reactive protein levels normalized.

Trigeminal trophic syndrome is a rare disease following peripheral or central damage to the fifth cranial nerve.¹^,2 Unilateral ulcers in the sensory distribution of the trigeminal nerve are characteristic.² The ulcers are most frequently located in the area supplied by the maxillary division of the trigeminal nerve, that is, on the nasal ala, cheek, and upper lip, sparing the nasal tip.² Hypoesthesia is often combined with paresthesia in the form of a burning, crawling, and itching sensation. As a result, self-inflicted lesions develop, secondary to unconscious traumatic rubbing and scratching.² Like skin ulcers from external trauma in general, they typically have sharply demarcated, pauci-inflammatory borders and can be geometrically shaped. There is also the lack of a primary lesion such as pustule, vesicle, or inflammatory papule.

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Article Information

Corresponding Author: Beke Esther Linnemann, Department of Dermatology, University of Lübeck, Ratzeburger Allee 160, Lübeck, Germany (bekeesther.linnemann@uksh.de).

Published Online: July 19, 2021. doi:10.1001/jamaneurol.2021.2236

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information. We also thank Ewan A. Langan, MD, University of Lübeck, Lübeck, Germany, for critically reading the manuscript. He was not compensated for his contribution to this work.

References

Bolaji RS , Burrall BA , Eisen DB . Trigeminal trophic syndrome: report of 3 cases affecting the scalp. Cutis. 2013;92(6):291-296.PubMed Google Scholar

Khan AU , Khachemoune A . Trigeminal trophic syndrome: an updated review. Int J Dermatol. 2019;58(5):530-537. doi:10.1111/ijd.14098 PubMed Google Scholar Crossref

Cardoso JC , Cokelaere K , Maertens M , Karim N , Jong TJ , Calonje E . When nonspecific histology can be a clue to the diagnosis: three cases of trigeminal trophic syndrome. Clin Exp Dermatol. 2014;39(5):596-599. doi:10.1111/ced.12332 PubMed Google Scholar Crossref

McDonald L , Baker G , Kerr O . Scalp ulceration: a rare manifestation of giant cell arteritis. BMJ Case Rep. 2019;12(11):e230795. doi:10.1136/bcr-2019-230795 PubMed Google Scholar

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.