Subacute Trismus in a Kidney Transplant Recipient

This case report describes a male patient with trismus and generalized muscle weakness as the presenting symptom of disseminated malignancy. Trismus was caused by the presence of multiple small nests of undifferentiated tumor cells between muscle fibers of the masseter muscles as well as of other skeletal muscles. The diagnosis was suggested by increased uptake of 18-fluoro-deoxyglucose on positron emission tomography and subsequent ultrasound examination. The primary tumor was not found on autopsy. The patient was at increased risk for malignancy due to his renal transplantation 16 years before.

malignancy;positron emission tomography;transplantation;trismus;weakness

1. Scully S, Hunt SR, Porter SR, Moos KF. Oral and maxillofacial disease, ed 3. London: Taylor & Francis, 2004.

2. Cawson RA, Odell EW. Cawson’s essentials of oral pathology and oral medicine, ed 8. Oxford: Churchill Livingstone,

3. Dhanrajani PJ, Jonaidel O. Trismus: Aetiology, differential diagnosis and treatment. Dent Update 2002;29:88–92, 94.

4. Garnett MJ, Nohl FS, Barclay SC. Management of patients with reduced oral aperture and mandibular hypomobility (trismus) and implications for operative dentistry. Br Dent J 2008;204:125–131.

5. Fagan JJ, Collins B, Barnes L, D’Amico F, Myers EN, Johnson JT. Perineural invasion in squamous cell carcinoma of the head and neck. Arch Otolaryngol Head Neck Surg 1998;124:637–640.

6. Vrielinck LJ, Ostyn F, van Damme B, van den BW, Fossion E. The significance of perineural spread in adenoid cystic carcinoma of the major and minor salivary glands. Int J Oral Maxillofac Surg 1988;17:190–193.

7. Haskova J, Maini S, Meehan C. Melanoma in the masseter muscle. J Laryngol Otol 2004;118:985–987.

8. Ariji Y, Fuwa N, Toyama M, Katoh M, Gotoh M, Ariji E. MR features of masticatory muscles in adenoid cystic carcinoma involving the masticator space. Dentomaxillofac Radiol 2004;33:345–350.

9. Euvrard S, Kanitakis J, Claudy A. Skin cancers after organ transplantation. N Engl J Med 2003;348:1681–1691.

10. Adami J, Gabel H, Lindelof B, et al. Cancer risk following organ transplantation: A nationwide cohort study in Sweden. Br J Cancer 2003;89:1221–1227.

11. London NJ, Farmery SM, Will EJ, Davison AM, Lodge JP. Risk of neoplasia in renal transplant patients. Lancet 1995;346:403–406.

12. Kauffman HM, Cherikh WS, Cheng Y, Hanto DW, Kahan BD. Maintenance immunosuppression with target-of-rapamycin inhibitors is associated with a reduced incidence of de novo malignancies. Transplantation 2005;80:883–889.

13. Flynn TR, Shanti RM, Levi MH, Adamo AK, Kraut RA, Trieger N. Severe odontogenic infections, part 1: Prospective report. J Oral Maxillofac Surg 2006;64:1093–1103.

14. Ridgway JM, Parikh DA, Wright R, et al. Lemierre syndrome: A pediatric case series and review of literature. Am J Otolaryngol 2010;31:38–45.

15. Leu YS, Lee JC, Chang KC. Submasseteric abscess: Report of two cases. Am J Otolaryngol 2000;21:281–283.

16. Sandyk R, Brennan MJ. Tuberculous meningitis presenting with trismus. J Neurol Neurosurg Psychiatry 1982;45:1070.

17. Proctor NS. Trismus in children with special reference to post-vaccinal encephalitis. S Afr Med J 1957;31:609–615.

18. Paterson AW, Ryan W, Rao-Mudigonda VV. Trismus: Or is it tetanus? A report of a case. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:437–441.

19. Schwab RA, Genners K, Robinson WA. Clinical predictors of mandibular fractures. Am J Emerg Med 1998;16:304–305.

20. Azaz B, Zeltser R, Nitzan DW. Pathoses of coronoid process as a cause of mouth-opening restrictions. Oral Surg Oral Med Oral Pathol 1994;77:579–584.

21. Krishnan A, Sleeman DJ, Irvine GH. Trismus caused by a retained foreign body in an adult. Oral Surg Oral Med Oral Pathol 1992;73:546–547.

22. Kruse AL, Dannemann C, Gratz KW. Bilateral myositis ossificans of the masseter muscle after chemoradiotherapy and critical illness neuropathy. Report of a rare entity and review of literature. Head Neck Oncol 2009;1:30.

23. Eipe N. The chewing of betel quid and oral submucous fibrosis and anesthesia. Anesth Analg 2005;100:1210–1213.

24. Yano H, Yamamoto H, Hirata R, Hirano A. Post-traumatic severe trismus caused by impairment of the masticatory muscle. J Craniofac Surg 2005;16:277–280.

25. Hilaire H, Weber WD, Ramer M, Lumerman H. Clinico-pathologic conference: Trismus following dental treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004; 98:261–266.

26. Stacy GC, Hajjar G. Barbed needle and inexplicable paresthesias and trismus after dental regional anesthesia. Oral Surg Oral Med Oral Pathol 1994;77:585–588.

27. Yoshida K. Coronoidotomy as treatment for trismus due to jaw-closing oromandibular dystonia. Mov Disord 2006; 21:1028–1031.

28. Cai XY, Yang C, Zhang ZY, Qiu WL, Chen MJ, Zhang SY. Septic arthritis of the temporomandibular joint: A retrospective review of 40 cases. J Oral Maxillofac Surg 2010;68:731–738.

29. Correa HC, Freitas AC, Da Silva AL, Coelho TK, Castillo DB, Vinholi GH. Joint disorder: Nonreducing disc displacement with mouth opening limitation. Report of a case. J Appl Oral Sci 2009;17:350–353.

30. Brown WA. Internal derangement of the temporomandibular joint: Review of 214 patients following meniscectomy. Can J Surg 1980;23:30–32.

31. Dijkstra PU, Kalk WW, Roodenburg JL. Trismus in head and neck oncology: A systematic review. Oral Oncol 2004; 40:879–889.

32. Dijkstra PU, Sterken MW, Pater R, Spijkervet FK, Roodenburg JL. Exercise therapy for trismus in head and neck cancer. Oral Oncol 2007;43:389–394.

33. Trumpy IG, Lyberg T. Temporomandibular joint dysfunction and facial pain caused by neoplasms. Report of three cases. Oral Surg Oral Med Oral Pathol 1993;76:149–152.

34. Cunningham PA, Kendrick RW. Trismus as a result of metoclopramide therapy. J Ir Dent Assoc 1988;34:128–129.

35. Louise KM, Brennan MT, Noll JL, et al. Radiation-induced trismus in head and neck cancer patients. Support Care Cancer 2008;16:305–309.

36. Carlos R, Contreras E, Cabrera J. Trismus-pseudocamp-todactyly syndrome (Hecht-Beals’ syndrome): Case report and literature review. Oral Dis 2005;11:186–189.

37. Bade DM, Lovasko JH, Montana J, Waide FL. Acute closed lock in a patient with lupus erythematosus: Case review. J Craniomandib Disord 1992;6:208–212.

38. Nir-Paz R, Gross A, Chajek-Shaul T. Reduction of jaw opening (trismus) in giant cell arteritis. Ann Rheum Dis 2002; 61:832–833.

39. Kadyan V, Clairmont AC, Engle M, Colachis SC. Severe trismus as a complication of cerebrovascular accident: A case report. Arch Phys Med Rehabil 2005;86:594–595.

40. D’Costa DF, Vania AK, Millac PA. Multiple sclerosis associ-ated with trismus. Postgrad Med J 1990;66:853–854.

41. Thompson TP, Jannetta PJ, Lovely TJ, Ochs M. Unilateral trismus in a patient with trigeminal neuralgia due to microvascular compression of the trigeminal motor root. J Oral Maxillofac Surg 1999;57:90–92.

42. Revington PJ, Peacock TR, Kingscote AD. Temporomandibular joint dysfunction: A case of hysterical trismus. Br Dent J 1985;158:55–56.

43. Mignot C, Doummar D, Maire I, De Villemeur TB. Type 2 Gaucher disease: 15 new cases and review of the literature. Brain Dev 2006;28:39–48.