- Email: [email protected]
Mental nerve neuropathy as a result of hepatitis B vaccination
M e n t a l nerve n e u r o p a t h y as a result of hepatitis B vaccination Jean F r a n c i s Maillefert, M D , a Pierre Farge, D D S , PhD, b M a r i e Pierre G a z e t - M a i l l e f e r t , c and Christian Tavernier, M D , a D i j o n and Lyon, F r a n c e CHU DIJON AND UNIVERS1TE LYON I We describe a 20-year-old woman who presented with polyarthralgia and sensory neuropathy, including mental nerve neuropathy. The symptoms were attributed to hepatitis B vaccination. This unusual cause of mental nerve neuropathy has not been previously described. However, as the use of hepatitis B vaccination is growing, adverse side effects, including mental nerve neuropathy, should be observed with an increased frequency. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:663-4)
In patients with m e n t a l nerve n e u r o p a t h y ( M N N ) , a c o m p l e t e dental history and evaluation, i n c l u d i n g diagnostic i m a g i n g , should b e d o n e to search for the m o s t c o m m o n causes such as trauma, dental treatment, l o c a l injection, infection, and b e n i g n or m a l i g nant p r i m a r y t u m o r s in the m e n t a l nerve area. O n c e such causes h a v e b e e n eliminated, s y s t e m i c causes m u s t be considered. M N N , in c o n j u n c t i o n with n o r m a l m a n d i b u l a r radiographs, has b e e n d e s c r i b e d as the first manifestation o f m a l i g n a n t diseasesl 1 O c c a s i o n a l l y , M N N is c a u s e d b y other s y s t e m i c diseases, such as vasculitis, 2 sarcoidosis, 3 or sickle cell crisis. 4' 5 W e w o u l d like to d r a w the readers attention to an u n c o m m o n cause o f MNN. CASE REPORT A 20-year-old woman was referred for polyarthralgia, pain in the inferior limbs, and paresthesia in the right lower lip. She had no relevant medical, facial trauma, or dental treatment history with the exception of having had extractions of four third molars 1 year before. Five weeks before admission, she was given Gen-HB-vax suspension. Three weeks later, she complained of acute neck pain. After 2 days, she developed a right hemifacial paresthesia and hypoesthesia. The symptoms rapidly resolved but persisted in the right lower lip area. One week later, she developed low-back pain, pain in the knees and shoulders, and pain and paresthesia in the inferior limbs. At entry, the patient appeared in good health. The back pain had spontaneously regressed but other complaints persisted. She was questioned about episodes of recent fe-
aDepartment of Rheumatology, CHU Dijon. bDepartment of Dentistry, Facult6 d'Odontologie, Universit6 Lyon I. CDental Resident, Facult6 d'Odontologie, Universit6 Lyon I. Received for publication Sept. 18, 1996; returned for revision Oct. 29, 1996; accepted for publication Jan. 8, 1997. Copyright © 1997 by Mosby Year Book, Inc. 107%2104/97/$5.00 + 0 7113180433
ver, infection, trauma, or dental procedures. There were no such events that could be associated with the complaints. Examination revealed an anesthesia of the skin and mucosa over the distribution of the right mental nerve. The orofacial examination did not reveal any other abnormality. The general examination did not demonstrate any other neurologic disturbance. The vertebral column was normal; the palpation of the knees and the scapulo-humeral joints was painful but there was no swelling of these joints. Laboratory tests revealed an elevation of the erythrocyte sedimentation rate (44 mm per hour) and C-reactive protein (44 mg/I; N < 5). The blood cell count, liver function tests, and lactate dehydrogenases were in the normal range. Cerebrospinal fluid examination was normal. There was no proteinuria, hematuria, or leukocyturia. The serum antistreptolysins were normal. Results of other serologic examinations (infectious mononucleosis, brucellosis, toxoplasmosis, Lyme arthritis, reactive arthritis, HIV) were negative. The tests for rheumatoid factors, antinuclear antibodies, circulating immune complexes (Clq deviation test), cryoglobulinemia was negative. Other investigations including panoramic, facial, skull, chest and articular radiographs, bone marrow examination, abdominal ultrasound, thoraco-abdominal CT-scan, bone scintigraphy, and electromyography of the inferior limbs did not reveal any abnormality. The patient was treated with nonsteroid inflammatory drugs. Two weeks later, the symptoms had completely regressed, and the erythrocyte sedimentation rate and Creactive protein were within normal limits. Consequently, the therapy was discontinued. Nine months later, she was in good health and had no recurrent attacks. DISCUSSION This patient p r e s e n t e d with a sensory neuropathy, including M N N , and a p o l y a r t h r o p a t h y . M N N has b e e n attributed to viruses 6 and to p o s t v a c c i n a l vasculitis 2 but, to our k n o w l e d g e , the o c c u r r e n c e o f M N N after hepatitis B v a c c i n a t i o n has not b e e n described. H o w e v e r , w e b e l i e v e that hepatitis B v a c c i n a t i o n was the etiologic factor o f M N N . T h e d e l a y o f occurrence and the e v o l u t i o n o f M N N was suggestive o f the re663
664
Maillefertet al.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
June 1997
sponsibility of vaccination. Arthropathies, which are a known adverse side effect of hepatitis B vaccination, 7 were observed and regressed simultaneously. Finally, no other cause could be found to explain the symptoms. Circulating immune complexes may play a role in hepatitis B infection-induced arthritis. Thus it is possible that the formation and deposit of such compounds containing surface-antigen and anti-HBs antibodies in the vasa nervorum and the synovial vessel walls are implicated in our patient. No circulating immune complexes were identified, but the laser nephelometric method is not sensitive enough to exclude their presence. In conclusion, this observation suggests that MNN can be induced by hepatitis B vaccination. Because vaccination with purified hepatitis B surface antigen is a useful and safe way to prevent infection, its use is growing in risk groups and in the general population. Thus adverse side-effects, possibly including MNN, should be observed with an increased frequency. Consequently, this cause of MNN is of particular interest to the dental specialist.
O
REFERENCES
1. Wayne ME, Moore J, Clifford SS. Mental neuropathy from systemic cancer. Neurology 1981;31:1277-81. 2. Delattre JY, Cabane J, Haguenan M. Neuropathie mentonnitre au cours d'une vascularite. Presse Med 1986;15:930. 3. Cohen DM, Reinhardt RA. Systemic sarcoidosis presenting with Homer's syndrome and mandibular paresthesia. Oral Surg Oral Med Oral Pathol 1982;53:577-8l. 4. Konotey-Ahulu FID. Mental nerve neuropathy: a complication of sickle-cell crisis. Lancet 1972;ii:388. 5. Kirson LE, Tomaro AJ. Mental nerve paresthesia secondary to sickle-cell crisis. Oral Surg Oral Med Oral Pathol 1979; 48:509-12. 6. Seward MHE. Anaesthesia of the lower lip: a problem in differential diagnosis. Br Dent J 1962;18:423-6. 7. Gross K, Combe C, Kriiger K, Schattenkirchner M. Arthritis after hepatitis B vaccination. Scand J Rheumatol 1995;24:50-2.
Reprint requests: JF Maillefert, MD Service de Rhumatologie, CHU Dijon, Htpital Gtntral, 3 rue du Fb Raines, 21000 Dijon, France
N THE MOVE?
D o n ' t miss a single issue of the journal! To ensure p r o m p t service w h e n y o u change y o u r address, please p h o t o c o p y a n d complete the f o r m below.
Please send your change of address notification at least six weeks before your move to ensure continued service. We regret we cannot guarantee replacement of issues missed due to late notification. JOURNAL TITLE: Fill in the title of the journal here.
OLD ADDRESS:
NEW ADDRESS:
Affix the address label from a recent issue of the journal here.
Clearly print your new address here. Name Address
City~State~ZIP
COPY A N D MAIL THIS FORM TO: Journal Subscription Services Mosby-Year Book, Inc. 11830 Westline Industrial Dr. St. Louis, MO 63146-3318
OR FAX TO: 314-432-1158
Mosby
OR PHONE: 1-800-453-4351 Outside the U.S., call 314-453-4351
In patients with m e n t a l nerve n e u r o p a t h y ( M N N ) , a c o m p l e t e dental history and evaluation, i n c l u d i n g diagnostic i m a g i n g , should b e d o n e to search for the m o s t c o m m o n causes such as trauma, dental treatment, l o c a l injection, infection, and b e n i g n or m a l i g nant p r i m a r y t u m o r s in the m e n t a l nerve area. O n c e such causes h a v e b e e n eliminated, s y s t e m i c causes m u s t be considered. M N N , in c o n j u n c t i o n with n o r m a l m a n d i b u l a r radiographs, has b e e n d e s c r i b e d as the first manifestation o f m a l i g n a n t diseasesl 1 O c c a s i o n a l l y , M N N is c a u s e d b y other s y s t e m i c diseases, such as vasculitis, 2 sarcoidosis, 3 or sickle cell crisis. 4' 5 W e w o u l d like to d r a w the readers attention to an u n c o m m o n cause o f MNN. CASE REPORT A 20-year-old woman was referred for polyarthralgia, pain in the inferior limbs, and paresthesia in the right lower lip. She had no relevant medical, facial trauma, or dental treatment history with the exception of having had extractions of four third molars 1 year before. Five weeks before admission, she was given Gen-HB-vax suspension. Three weeks later, she complained of acute neck pain. After 2 days, she developed a right hemifacial paresthesia and hypoesthesia. The symptoms rapidly resolved but persisted in the right lower lip area. One week later, she developed low-back pain, pain in the knees and shoulders, and pain and paresthesia in the inferior limbs. At entry, the patient appeared in good health. The back pain had spontaneously regressed but other complaints persisted. She was questioned about episodes of recent fe-
aDepartment of Rheumatology, CHU Dijon. bDepartment of Dentistry, Facult6 d'Odontologie, Universit6 Lyon I. CDental Resident, Facult6 d'Odontologie, Universit6 Lyon I. Received for publication Sept. 18, 1996; returned for revision Oct. 29, 1996; accepted for publication Jan. 8, 1997. Copyright © 1997 by Mosby Year Book, Inc. 107%2104/97/$5.00 + 0 7113180433
ver, infection, trauma, or dental procedures. There were no such events that could be associated with the complaints. Examination revealed an anesthesia of the skin and mucosa over the distribution of the right mental nerve. The orofacial examination did not reveal any other abnormality. The general examination did not demonstrate any other neurologic disturbance. The vertebral column was normal; the palpation of the knees and the scapulo-humeral joints was painful but there was no swelling of these joints. Laboratory tests revealed an elevation of the erythrocyte sedimentation rate (44 mm per hour) and C-reactive protein (44 mg/I; N < 5). The blood cell count, liver function tests, and lactate dehydrogenases were in the normal range. Cerebrospinal fluid examination was normal. There was no proteinuria, hematuria, or leukocyturia. The serum antistreptolysins were normal. Results of other serologic examinations (infectious mononucleosis, brucellosis, toxoplasmosis, Lyme arthritis, reactive arthritis, HIV) were negative. The tests for rheumatoid factors, antinuclear antibodies, circulating immune complexes (Clq deviation test), cryoglobulinemia was negative. Other investigations including panoramic, facial, skull, chest and articular radiographs, bone marrow examination, abdominal ultrasound, thoraco-abdominal CT-scan, bone scintigraphy, and electromyography of the inferior limbs did not reveal any abnormality. The patient was treated with nonsteroid inflammatory drugs. Two weeks later, the symptoms had completely regressed, and the erythrocyte sedimentation rate and Creactive protein were within normal limits. Consequently, the therapy was discontinued. Nine months later, she was in good health and had no recurrent attacks. DISCUSSION This patient p r e s e n t e d with a sensory neuropathy, including M N N , and a p o l y a r t h r o p a t h y . M N N has b e e n attributed to viruses 6 and to p o s t v a c c i n a l vasculitis 2 but, to our k n o w l e d g e , the o c c u r r e n c e o f M N N after hepatitis B v a c c i n a t i o n has not b e e n described. H o w e v e r , w e b e l i e v e that hepatitis B v a c c i n a t i o n was the etiologic factor o f M N N . T h e d e l a y o f occurrence and the e v o l u t i o n o f M N N was suggestive o f the re663
664
Maillefertet al.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
June 1997
sponsibility of vaccination. Arthropathies, which are a known adverse side effect of hepatitis B vaccination, 7 were observed and regressed simultaneously. Finally, no other cause could be found to explain the symptoms. Circulating immune complexes may play a role in hepatitis B infection-induced arthritis. Thus it is possible that the formation and deposit of such compounds containing surface-antigen and anti-HBs antibodies in the vasa nervorum and the synovial vessel walls are implicated in our patient. No circulating immune complexes were identified, but the laser nephelometric method is not sensitive enough to exclude their presence. In conclusion, this observation suggests that MNN can be induced by hepatitis B vaccination. Because vaccination with purified hepatitis B surface antigen is a useful and safe way to prevent infection, its use is growing in risk groups and in the general population. Thus adverse side-effects, possibly including MNN, should be observed with an increased frequency. Consequently, this cause of MNN is of particular interest to the dental specialist.
O
REFERENCES
1. Wayne ME, Moore J, Clifford SS. Mental neuropathy from systemic cancer. Neurology 1981;31:1277-81. 2. Delattre JY, Cabane J, Haguenan M. Neuropathie mentonnitre au cours d'une vascularite. Presse Med 1986;15:930. 3. Cohen DM, Reinhardt RA. Systemic sarcoidosis presenting with Homer's syndrome and mandibular paresthesia. Oral Surg Oral Med Oral Pathol 1982;53:577-8l. 4. Konotey-Ahulu FID. Mental nerve neuropathy: a complication of sickle-cell crisis. Lancet 1972;ii:388. 5. Kirson LE, Tomaro AJ. Mental nerve paresthesia secondary to sickle-cell crisis. Oral Surg Oral Med Oral Pathol 1979; 48:509-12. 6. Seward MHE. Anaesthesia of the lower lip: a problem in differential diagnosis. Br Dent J 1962;18:423-6. 7. Gross K, Combe C, Kriiger K, Schattenkirchner M. Arthritis after hepatitis B vaccination. Scand J Rheumatol 1995;24:50-2.
Reprint requests: JF Maillefert, MD Service de Rhumatologie, CHU Dijon, Htpital Gtntral, 3 rue du Fb Raines, 21000 Dijon, France
N THE MOVE?
D o n ' t miss a single issue of the journal! To ensure p r o m p t service w h e n y o u change y o u r address, please p h o t o c o p y a n d complete the f o r m below.
Please send your change of address notification at least six weeks before your move to ensure continued service. We regret we cannot guarantee replacement of issues missed due to late notification. JOURNAL TITLE: Fill in the title of the journal here.
OLD ADDRESS:
NEW ADDRESS:
Affix the address label from a recent issue of the journal here.
Clearly print your new address here. Name Address
City~State~ZIP
COPY A N D MAIL THIS FORM TO: Journal Subscription Services Mosby-Year Book, Inc. 11830 Westline Industrial Dr. St. Louis, MO 63146-3318
OR FAX TO: 314-432-1158
Mosby
OR PHONE: 1-800-453-4351 Outside the U.S., call 314-453-4351