A 39-Year-Old Woman With Facial Twitches

Kenneth B.V. Gross, MD


July 03, 2018

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to recognize accurately. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


A 39-year-old black woman presents to the emergency department with a rash and fever. She has reportedly been ill for about a week, and her fever had reached 103°F (39.4°C). The rash is near her ear. Over the past 2 days, she has noted intermittent facial twitches and tongue extrusions (see Figure 1), and attributes that to feeling nervous about her recent illness.

Figure 1.

The patient has a history of mild hypertension. She admits to occasional marijuana and cocaine use 20 years ago, with no use of any drugs over recent months. Her alcohol use was sporadic over the past 10 years, with limited use (three glasses of wine per week) over the past 6 months. The patient's medications include hydrochlorothiazide for hypertension.

The patient has a remote history of depression, for which she had been given duloxetine and citalopram. She has been pregnant four times, with two spontaneous abortions for unknown reasons and two pregnancies carried to delivery, producing two healthy children now in their late teens. The pregnancies that were carried to term were uneventful except for severe morning sickness, for which she was given metoclopramide. She has no known allergies or family history of relevant diseases. The patient works as a federal government clerk.


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