Facial nerve paralysis affecting the lower motor neuron (LMN) presents as weakness of both the upper and lower facial muscles ipsilaterally. While most cases stem from idiopathic Bell’s palsy, rare bacterial infections—including typhoid fever—can also trigger such neurological outcomes. In regions where typhoid remains common, clinicians should remain vigilant for post-infectious cranial neuropathies. Here we present a case of Facial palsy after Typhoid fever.
This 32 year old male with no known co-morbidities initially presented to outside hospital with fever associated with abdominal pain for 1 week and was managed conservatively. He was referred to our hospital during 2nd week of illness and blood cultures grew Salmonella. Subsequently on routine follow up at the end of 3rd week of illness, he complained of mouth deviation to left side and eye closure on right side.
Typhoid fever, caused by Salmonella enterica serovar Typhi, spreads via ingestion of contaminated food or water. The bacteria invade Peyer’s patches and lymphoid tissues, later disseminating systemically to organs such as the liver, spleen, and bone marrow . Symptoms range from persistent fever and abdominal discomfort to hepatosplenomegaly and characteristic rose spots. Notably, severe complications including hemorrhage, bowel perforation, and neurologic involvement may occur, especially in the third week of illness .
Though uncommon, neurological complications affect a minority of typhoid patients. In a study of nearly a thousand hospitalized cases in Nigeria, 0.5% developed infranuclear facial palsy, alongside other rare manifestations like hemiplegia and meningitis . Broader surveys show that polymorphic neurological manifestations—such as myelitis, cerebellitis, and peripheral neuropathy—are well documented but rare .
Case series involving children document isolated cranial nerve involvement (e.g., palatal or abducens palsy) during typhoid illness, resolving after appropriate antimicrobial therapy . Reports also show sixth nerve palsy and diplopia improving with treatment .
Unlike herpesviruses, S. Typhi doesn’t directly infect neurons. Possible mechanisms may include:
-Immune-mediated nerve injury: Similar to Guillain–Barré syndrome, antibodies triggered by typhoid could cross-react with nerve components, especially myelin.
-Toxin-induced vascular dysfunction: Salmonella endotoxins may cause small‑vessel injury, compromising facial nerve perfusion.
-Indirect inflammatory damage: Systemic inflammation may trigger demyelination or neuritis around cranial nerves.
These mechanisms align with other rare cases—such as cranial neuropathies seen in scrub typhus or leptospirosis—which similarly resolve with antimicrobial and immunomodulatory treatment .
Patients typically present after the acute febrile phase, though onset may overlap. Key features include:
Sudden unilateral facial weakness affecting eye closure and smile
Flattened nasolabial fold and impaired forehead movement on the affected side
Possible hyperacusis, altered taste, or reduced lacrimation
No involvement of limbs or other cranial nerves unless part of broader neuropathy
The condition is often painless and without rash or ear involvement, helping distinguish it from Ramsey Hunt syndrome.
A systematic evaluation should include:
Fever timeline, typhoid confirmation (culture or serology)
CSF analysis to rule out meningitis if neurological signs extend beyond facial nerve
MRI with contrast can reveal enhancement along the facial nerve in neuritis and exclude central lesions.
Help differentiate demyelinating vs axonal damage and inform prognosis.
Antimicrobial Therapy:
If typhoid is still present, treat with appropriate antibiotics (e.g., ceftriaxone, azithromycin).
Corticosteroids (e.g., prednisolone) are commonly used in idiopathic facial palsy and adopted here, often for 7–10 days.
IVIG or plasmapheresis may be considered if facial palsy coexists with features of GBS.
Eye care: lubrication, taping eyelid at night
Physical therapy: guided facial muscle exercises
Monitor recovery over 4–8 weeks; follow up with electrophysiology as needed
Most patients with isolated facial palsy recover fully over weeks to a few months. When associated with GBS variants, recovery may take longer, and residual deficits are possible. Early immunotherapy tends to improve outcomes.
Alternatives to consider include:
Bell’s palsy: idiopathic facial palsy without systemic illness.
Ramsay Hunt syndrome: facial palsy with vesicular rash and ear pain.
Lyme disease: would require travel history; often bilateral palsy.
GBS variants: if limb weakness or areflexia is present.
Meningitis or neuroinfections: typically show more systemic CNS signs.
Sarcoidosis / Heerfordt syndrome: facial palsy with uveitis and parotid enlargement .
Although exceedingly uncommon, LMN facial palsy may occur in association with typhoid fever, likely through immune-mediated or toxin-associated mechanisms. Recognition of the temporal relationship and exclusion of other causes are crucial. With timely antibiotic therapy and judicious use of steroids or IVIG, most patients recover well—often fully within weeks. As clinicians in endemic areas, maintaining awareness of this rare neurological complication aids early intervention and better outcomes.
– Cranial Nerve Palsy and Diplopia in Typhoid Fever
A 2023 case report details an adult with typhoid fever who developed sixth cranial nerve palsy, presenting as diplopia, without signs of meningitis; symptoms resolved with antibiotics.
– Typhoid Fever with Isolated Left Lateral Rectus Palsy
A 17-year-old female with culture-confirmed typhoid developed isolated abducens nerve palsy, leading to diplopia. She improved with azithromycin and oral steroids.
– Cranial Nerve Palsies in Children with Typhoid Fever
A case series describing three pediatric patients (ages 4–11) with culture-proven typhoid fever who developed palatal or sixth cranial nerve palsy, all of whom fully recovered in 5–7 weeks.
– Typhoid Fever with Neurological Presentation
A 2025 report of a 31-year-old male with typhoid fever presenting with aseptic meningitis, optic neuritis, and bilateral sixth nerve palsy; managed successfully with ceftriaxone and corticosteroids.
– Diplopia from Sixth Nerve Palsy Without Intracranial Lesions
Another case report emphasizes that even without radiologic findings or meningitis, typhoid fever can cause isolated sixth nerve palsy.
Dr Ramapriya S, MBBS, MD, DrNB Critical Care Postgraduate Kauvery Hospital Chennai
Dr Vetriselvan P, MBBS, MD, DM Associate Consultant Critical Care Consultant, Kauvery Hospital Chennai
