Tophaceuos calcium pyrophosphate dihydrate deposition disease of the temporomandibular joint: the preferential site?

Treatment of tophaceous pseudogout in the temporomandibular joint with resection and alloplastic reconstruction: a single-staged approach

Tophaceous pseudogout is a rare variant of the calcium pyrophosphate dihydrate (CPPD) disorder, with predilection for the TMJ. It is characterized by calcific deposits composed of rhomboid- or rectangular-shaped crystals that exhibit birefringence when examined under polarized light. We hereby present a case of a 65-year-old man with left pre-auricular tenderness and malocclusion. CT imaging was notable for a left TMJ mineralized mass with erosion of the condylar head. Treatment involved excision of the mass with eminectomy, condylectomy, and a stock total TMJ reconstruction. In this report, important considerations for diagnosis, biopsy, and surgical treatment with emphasis on reconstruction for tophaceous pseudogout of the TMJ have been highlighted by the authors.

Calcium Pyrophosphate Crystal Deposition in a Cohort of 57 Patients with Gitelman Syndrome

OBJECTIVE

Gitelman syndrome (GS) is the most frequent salt-wasting genetic tubulopathy and a source of hypokalaemia and hypomagnesemia. Chondrocalcinosis (CC) is a frequent feature of GS. The aim of our study was to determine the prevalence, distribution patterns, clinical phenotypes and risk factors of CC in GS.

METHODS

This prospective study of a cohort of 57 patients with GS included a systematic screening for CC by peripheral joint radiography, cervical spine computerized tomography (CT) and joint ultrasonography. The prevalence of cervical C1-C2 CC by CT was compared between 33 GS patients and sex- and age-matched controls. Clinical and biochemical features were analysed to identify factors associated with CC.

RESULTS

Mean age of patients was 46.5 ± 12.4 years, 66.7% were women, and 93.0% carried SLC12A3 mutations. Mean serum magnesium level was 0.60 ± 0.30 mmol/l. CC was observed in 79% of patients, with the highest prevalence at the cervical spine (81.8%) followed by the knee (52.6%), wrist (50.9%), ankle (38.6%), temporomandibular joint (36.4%), shoulder (33.3%), hip (22.8%), elbow (14.0%) and sclero-choroid (12.1%). Prevalence of CC at the C1-C2 level was higher in the GS cohort than control group (72.7% vs 9.1%) (adjusted odds ratio 21.0, 95% CI 2.8-156.1, p= 0.003). Independent factors associated with CC were low serum magnesium level and age.

CONCLUSION

GS was associated with widespread CC, favoured by aging and hypomagnesemia. The C1-C2 level was the most affected site. Follow-up of this unique cohort will help understanding the clinical consequences of CC, especially the precise characterization of pyrophosphate arthropathy.

Nodular Pseudogout of the Skull Base Arising From the Temporomandibular Joint

ABSTRACT

The authors report a case of a rare, large, nodular pseudogout which developed from the temporomandibular joint (TMJ).An 83-year-old female was referred to the hospital with swelling on her left cheek. Imaging studies revealed a large calcified mass surrounding the left mandibular condyle, partially destroying the adjoining bone and extending to the skull base. Magnetic resonance imaging (MRI) revealed soft tissue masses with low signal intensity on T1- and T2-weighted images and were enhanced after intravenous gadolinium injection.The mass was clinically and radiologically suspected to be a neoplastic lesion, such as chondrosarcoma or fibrous dysplasia. However, histological analysis showed that the mass contained granulomatous lesions with numerous multiple nodular rod-shaped and diamond-shaped crystal deposits, which validated the diagnosis of pseudogout. X-ray diffraction (XRD) was performed to identify the tumor's deposited materials and revealed that these were calcium pyrophosphate dihydrate (CPPD) crystals. This result confirmed the histopathological diagnosis of "tophaceous pseudogout."

Calcium pyrophosphate deposition disease of the temporomandibular joint invading the middle cranial fossa: Two case reports

BACKGROUND

Pseudogout is a benign joint lesion caused by the deposition of calcium pyro-phosphate dihydrate crystals, but it is invasive. Pseudogout of the temporo-mandibular joint (TMJ) is uncommon, and it rarely invades the skull base or penetrates into the middle cranial fossa. The disease has no characteristic clinical manifestations and is easily misdiagnosed.

CASE SUMMARY

We present two cases of tophaceous pseudogout of the TMJ invading the middle cranial fossa. A 46-year-old woman with a history of diabetes for more than 10 years was admitted to the hospital due to swelling and pain in the right temporal region. Another patient, a 52-year-old man with a mass in the left TMJ for 6 years, was admitted to the hospital. Maxillofacial imaging showed a calcified mass and severe bone destruction of the skull base in the TMJ area. Both patients underwent excision of the lesion. The lesion was pathologically diagnosed as tophaceous pseudogout. The symptoms in these patients were relieved after surgery.

CONCLUSION

Tophaceous pseudogout should be considered when there is a calcified mass in the TMJ with or without bone destruction. A pathological examination is the gold standard for diagnosing this disease. Surgical treatment is currently the recommended treatment, and the prognosis is good after surgery.

Tophaceous pseudogout of the temporomandibular joint with erosion into the middle cranial fossa

This report presents a case of extensive tophaceous pseudogout involving the temporomandibular joint (TMJ), causing erosion into the middle cranial fossa. Pseudogout is a benign metabolic arthropathy caused by calcium pyrophosphate dihydrate crystal deposition within joints and peri-articular tissue. Pseudogout more frequently occurs in large joints such as the knee, wrist, symphysis pubis, and shoulder. Tophaceous pseudogout involving the TMJ is rare, with only seven cases involving erosion into the middle cranial fossa reported previously. Despite skull base erosion being a rare consequence of this erosive disease, this case highlights the importance of appropriate investigation and multidisciplinary team management.

Treatment of calcium pyrophosphate deposition in the temporomandibular joint with resection and simultaneous reconstruction using a custom joint prosthesis

PURPOSE

The authors present a rare case of calcium pyrophosphate deposition disease (CPPD) in the temporomandibular joint (TMJ), successfully treated with complete resection and immediate reconstruction using a custom-made prosthesis. This one-stage approach has prevented the patient from requiring two surgeries and has proven effective in the management of the condition.

METHODS

Our patient, a 56-year-old male, presented with left TMJ pain and trismus. Investigations showed a destructive left TMJ mass, confirmed by biopsy to be tophaceous pseudogout. The treatment involved excising all the affected tissues followed by condylectomy, coronoidectomy, and a total TMJ replacement. The patient recovered well from surgery with good mouth opening.

RESULTS

CPPD disease is a metabolic arthropathy of poorly understood aetiology. Management options vary from conservative non-surgical to surgical treatment depending on the severity.

CONCLUSION

This case demonstrates the feasibility of a one-stage procedure with reconstruction using a custom-made prosthesis and virtual planning.

Tophaceous Gout of the Middle Ear: Case Reports and Review of the Literature

Tophaceous gout of the middle ear is a rare occurrence that presents as a granular white-colored mass. It is frequently misdiagnosed as cholesteatoma or tympanosclerosis in patients who otherwise may not manifest any clinical or biochemical signs of gout. While uncommon, it can lead to clinically significant disease such as conductive hearing loss. The present report describes 2 cases of middle ear gouty tophi initially mistaken for another entity. Both patients underwent surgery, and the diagnosis of gout was revealed after final histopathological analysis. A review of the literature is also presented.

Atypical Tumoral Presentation of Calcium Pyrophosphate Deposition Disease: A Case Report

CASE

A 55-year-old man presented with a history of forefoot pain and swelling. Radiographs revealed a mass with internal calcifications and osseous erosion of the fifth metatarsophalangeal bone. The mass was isointense to muscle on T1-weighted magnetic resonance imaging (MRI) and hyperintense on T2-weighted MRI. A biopsy was performed, and intraoperatively, the lesion appeared as chalky white material, which under polarized light microscopy was composed of weakly positively birefringent rhomboid crystals, leading to a diagnosis of tophaceous pseudogout.

CONCLUSION

Tophaceus pseudogout should be included in the differential diagnosis of neoplastic-appearing lesions in the foot, and polarized light microscopy should be used when examining biopsy specimens.

Imaging Approach to Temporomandibular Joint Disorders

Internal derangement is the most common temporomandibular joint disorder. Degenerative osteoarthritis and trauma are next in frequency. Less common pathology includes rheumatoid arthritis, synovial chondromatosis, calcium pyrophosphate dehydrate deposition disease, pigmented villonodular synovitis, tumors, infection, and osteonecrosis. We provide a systematic approach to facilitate interpretation based on major anatomic structures: disc-attachments, joint space, condyle, and lateral pterygoid muscle. Relevant graphic anatomy and state of the art imaging are discussed in correlation with current clinical and therapeutic highlights of pathologic entities affecting the joint.