Abstract

Introduction

Trigeminal autonomic cephalalgias (TACs) are rare primary headache syndromes characterized by trigeminal pain distribution and ipsilateral autonomic symptoms, affecting 0.1% of the population. Conversely, cellulitis is a common bacterial skin infection causing inflammation, typically presenting as poorly demarcated erythema, warmth, edema, and tenderness.

 

Case

An 81-year-old female with a history of head and facial injury after a fall presented with worsening right-sided facial swelling, redness, pain, fever, and chills, and was diagnosed with Streptococcus pyogenes bacteremia secondary to facial cellulitis. She was treated with IV Antibiotics and then discharged on oral Cefuroxime. Despite being on antibiotics, she returned to the clinic with new complaints of severe, stabbing headaches and episodic facial swelling needing more antibiotics. She was readmitted to the hospital with severe debilitating episodic headaches, nausea and photophobia, conjunctival injection, facial pain, and swelling, and unresponsive to antibiotics. All workups for orbital cellulitis came back negative and Neurology was consulted. She was eventually diagnosed with TAC post-workup. Gabapentin was initiated, leading to symptom resolution on a tapered regimen.

 

Discussion

While facial cellulitis and TAC are typically not considered differentials for each other, this case is unique. The patient was initially diagnosed with facial cellulitis but was unresponsive to a prolonged antibiotic regimen despite improvement seen in lab values and CT imaging. Additional severe cluster headaches and conjunctival injection led to a diagnosis of TAC and her symptoms resolved after she was started on Gabapentin.  TAC is a short-lasting unilateral headache with at least one autonomic ipsilateral symptom to the headache, such as lacrimation, nasal congestion, edema, conjunctival injection, or aural fullness. In cases of post-traumatic facial injury with symptoms manifesting in a trigeminal distribution, considering TAC in the differentials of Facial cellulitis due to potential trigeminal sensitization is important.

 

References

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