What is the likely cause of jaw and neck pain in a post-rhinoplasty patient with a Goretex implant, on cefuroxime and doxycycline for a possible infection, who developed symptoms after tirzepetide injection?

Jaw and Neck Pain After Tirzepatide Injection: Most Likely Cause

The jaw and neck pain that developed one hour after tirzepatide injection is most likely an adverse reaction to tirzepatide itself, not related to the antibiotics or the underlying rhinoplasty infection. This temporal relationship—symptoms appearing within one hour of injection—strongly implicates tirzepatide as the causative agent.

Understanding the Clinical Scenario

You are managing a post-rhinoplasty patient with a Goretex implant infection at 2 months, which you appropriately aspirated and cultured, then started on cefuroxime and doxycycline. The timing of symptom onset is critical here:

• Jaw and neck pain appeared within 1 hour of tirzepatide administration
• This temporal relationship is too rapid to represent infection progression or antibiotic reaction
• The antibiotics (cefuroxime and doxycycline) were appropriate choices for suspected implant-associated infection, as they provide coverage against Staphylococcus aureus and other common pathogens 1

Why Tirzepatide Is the Likely Culprit

Tirzepatide is a GLP-1 receptor agonist used for diabetes and weight management, and musculoskeletal pain is a recognized adverse effect. While not specifically listed as "jaw and neck pain" in typical adverse event profiles, GLP-1 agonists can cause:

• Injection site reactions
• Myalgia and arthralgia
• Gastrointestinal symptoms that may manifest as referred pain to jaw/neck
• Rare hypersensitivity reactions

The one-hour timeframe is consistent with an acute drug reaction rather than:

• Infection progression (would take hours to days)
• Antibiotic side effects (typically take longer to manifest, except for immediate hypersensitivity)
• Septic spread from the nasal implant (would present with systemic signs like fever, worsening nasal symptoms)

What This Is NOT

Not Antibiotic-Related

• Cefuroxime and doxycycline do not typically cause acute jaw/neck pain within one hour 1, 2
• Antibiotic side effects usually include gastrointestinal symptoms, rash, or (rarely) immediate hypersensitivity reactions
• The combination of cefuroxime and doxycycline is reasonable for covering both methicillin-susceptible and resistant organisms in implant infections 1

Not Infection Progression

• Goretex implant infections typically present with local signs: erythema, swelling, purulent drainage, and tenderness at the implant site 3, 4, 5, 6
• Infection rates with Goretex in rhinoplasty range from 1.2% in primary cases to 5.4% in revision cases 3
• Systemic spread would manifest with fever, chills, and worsening local symptoms—not isolated jaw/neck pain one hour after an unrelated injection 3, 4

Immediate Management Steps

1. Assess for Serious Complications

• Rule out angioedema or anaphylaxis: Check for tongue swelling, throat tightness, difficulty breathing, or urticaria
• Evaluate for myocardial ischemia: Although unlikely in this context, jaw pain can be cardiac in origin—check vital signs, obtain ECG if any concern
• Assess for meningeal signs: Neck stiffness with fever could indicate CNS infection, though this would be extraordinarily rare and not temporally related to tirzepatide

2. Supportive Care for Tirzepatide Reaction

• Discontinue tirzepatide and observe the patient
• Administer analgesics (acetaminophen or NSAIDs) for symptomatic relief
• Monitor for progression over the next 24-48 hours
• If symptoms resolve, this confirms tirzepatide as the cause

3. Continue Appropriate Antibiotic Therapy for the Implant Infection

• Your antibiotic choice (cefuroxime + doxycycline) is reasonable for covering common nasal implant pathogens 1, 7
• However, consider switching to a more definitive regimen based on culture results when available
• For Goretex implant infections, removal is often necessary if antibiotics fail to resolve the infection within 48-72 hours 3, 4, 5, 6

Addressing the Underlying Goretex Implant Infection

Antibiotic Selection

• Cefuroxime provides good coverage for Staphylococcus aureus and streptococci 1, 7
• Doxycycline adds coverage for atypical organisms and some resistant strains 1
• If MRSA is suspected or confirmed, consider adding vancomycin, linezolid, or switching to a regimen with better MRSA coverage 1

When to Remove the Implant

• Goretex implant infections have a 3.2% overall removal rate, with higher rates (5.4%) in revision cases 3
• Indications for implant removal include:
  • Failure to improve after 48-72 hours of appropriate antibiotics 3, 4
  • Abscess formation 3
  • Persistent purulent drainage 3, 4
  • Systemic signs of infection (fever, elevated WBC) 3
• Preoperative nasal septal perforation is a contraindication for Goretex implantation and increases infection risk 3

Long-Term Considerations

• Goretex implants can develop late complications including tissue ingrowth, calcification, foreign body reactions, and structural changes over time 4
• Even if the current infection resolves, long-term stability should be monitored 4, 6

Critical Pitfalls to Avoid

• Do not attribute the jaw/neck pain to the nasal infection without considering the temporal relationship to tirzepatide
• Do not delay implant removal if the infection fails to respond to antibiotics within 72 hours 3, 4, 5
• Do not use first-generation cephalosporins (like cephalexin) for implant infections, as they have poor coverage against Haemophilus influenzae and other relevant pathogens 1, 2
• Do not assume all jaw/neck pain is benign—rule out serious causes like angioedema, cardiac ischemia, or CNS infection before attributing symptoms to a drug reaction

Summary Algorithm

1. Immediate assessment: Rule out angioedema, anaphylaxis, cardiac ischemia, and CNS infection
2. Discontinue tirzepatide and provide symptomatic relief with analgesics
3. Continue antibiotics for the implant infection (cefuroxime + doxycycline is reasonable pending cultures) 1, 7
4. Reassess at 48-72 hours: If nasal infection not improving, plan for Goretex implant removal 3, 4, 5, 6
5. Monitor jaw/neck pain resolution: If symptoms resolve after stopping tirzepatide, this confirms the diagnosis

The most likely cause of the jaw and neck pain is an adverse reaction to tirzepatide, given the one-hour temporal relationship. The antibiotics and underlying infection are unlikely culprits for this specific symptom presentation.