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‘Trismus’ after seizure from hepatopathy

Painless luxation of the temporo-mandibular joints has not been reported as a complication of seizure. In a 22-year-old woman (height 159 cm, weight 44 kg), with a history of recurrent nausea and diarrhoea since 1 year, and recurrent fever up to 39 C and 7 kg weight-loss in the 4 weeks prior to seeking treatment, a first generalized clonic–tonic seizure of approximately 3 min without aura but ‘cri epileptique’ occurred when bathing in a tub. During seizure boyfriend and father protected her from injury and drowning. There was no tongue bite or secessus, but post-ictal drowsiness and amnesia. Immediately afterwards, slurred speech and inability to open the mouth were recognized. The family history was positive for psychosis (brother) and elevated liver enzyme levels (brother, father, father’s grandfather). She was regularly taking the pill and acetylsalicylic acid (ASA, 500–600 mg/day) for chronic headache. She admitted occasional alcohol consumption. Neurologic examination revealed drowsiness, confusion, irritability, combativeness, dysarthria, indolent resistance to passive and voluntary mouth opening, asterixis, exaggerated tendon reflexes, positive pyramidal signs, and weakness of the hip flexors (M5) bilaterally. She could voluntarily open the mouth and stretch out the tongue. Brain computed tomography and electroencephalography were normal. Blood samples revealed increased total bilirubin (4.1 mg/dl; normal: £1.1 mg/dl), glutamate-oxalate transaminase (520 U/l; normal: £30 U/l), glutamate-pyruvate transaminase (186 U/l; normal: £33 U/l), gamma-glutamyl transpeptidase (4009 U/l; normal: £37 U/ l), creatine kinase (8352 U/l; normal: £144 U/l), amylase (396 U/l; normal: 28– 100 U/l), and lipase (1263 U/l; normal: 13–60 U/l). Ammonium was 53 lmol/l (normal: 10–48 lmol/l). Abdominal ultrasonography revealed hepatomegaly from steatosis. X-ray of the mandibular joints disclosed ventral dislocation of hypoplastic condyls bilaterally (Fig. 1). Acute repositioning required general anaesthesia. Clinical findings and the abnormal blood values steadily improved within 12 days. She did not develop a withdrawal syndrome. Based upon the history of nausea, diarrhoea, fever, encephalopathy following fever, long-term high-dose ASA intake, the cerebral manifestations, and hepatic failure, Reye syndrome was suspected. However, Reye syndrome is characterized by acute repetitive vomiting, followed by encephalopathy after a viral infection, although the term is also used for a group of heterogeneous disorders, characterized by non-specific liver dysfunction and encephalopathy, caused by infectious, metabolic, toxic or drug-induced disease [1]. Whether the long-term ASA misuse triggered encephalopathy remains speculative. The family history, the abnormal liver-function parameters, the reaction to ASA, which impairs respiratory chain functions and causes lactacidosis are all symptoms which are indicative of an underlying mitochondrial defect. An infection was rather excluded, given the normal white-cell blood count, erythrocyte sedimentation rate, hepatitis antibodies, C-reactive protein, and the absence of fever during hospitalization. Hepatopathy from alcoholism was regarded unlikely, as she did not drink alcohol regularly and did not develop withdrawal symptoms. Impaired mouth opening was initially classified as trismus, because of prolonged focal ictal activity. Misinterpretation occurred because mouth-opening was painless, temporo-mandibular joints did not hurt or crepitate on voluntary or passive movement, and there was only slight prognathia. The indolence of the luxation was attributed to the hepatic encephalopathy or post-ictal analgesia [2]. Possibly, ASA had an additional sedentary or analgesic effect. The luxation was attributed to the hypoplastic mandibular condyls, favouring displacement of the jaw during seizure, although the history for previous habitual jaw luxations or subluxation of the temporo-mandibular joints was negative. Possibly, the only slight hypoplasia prevented spontaneous luxation thus far. The seizure was most likely