1. U Tariq MD MBBS, E Wun DDS, J Smith MD MS, W Millar MD MS Geisinger Medical Center Danville, PA. NEUROIMAGING FINDINGS OF UNILATERAL TEMPOROMANDIBULAR JOINT MONOARTHRITIS CAUSED BY CPPD CRYSTAL DEPOSITION DISEASE Control #:1872 Poster #: E-17 GEISINGER Health System

2. DISCLOSURES The authors of this presentation have no disclosures. GEISINGER Health System

3. PURPOSE To describe the clinical presentation and neuroimaging findings of a rare and unusual case of unilateral temporomandibular joint (TMJ) arthritis due to calcium pyrophosphate dihydrate (CPPD) crystal deposition disease. GEISINGER Health System

4. CASE REPORT 66 year-old female with severe chronic intermittent pain in left TMJ for multiple years, worse with chewing and jaw activity. Physical examination and relative blood work was unremarkable. GEISINGER Health System

5. CT scan of the face showed a “ground glass”-like calcification infiltrating the left temporomandibular joint space with superimposed osteoarthritic degenerative changes at the left mandibular condyle and within mandibular fossa. Right TMJ was unremarkable. IMAGING FINDINGS

6.  Subsequent, magnetic resonance imaging (MRI) confirmed the CT findings  Intermediate T1 and mixed T2 signal infiltrates expanding the TMJ joint space

7.  Subsequent, magnetic resonance imaging (MRI) confirmed the CT findings  Intermediate T1 and mixed T2 signal infiltrates expanding the TMJ joint space

8. CASE REPORT CPPD crystal deposition disease was suggested as a probable diagnosis. Plain films of the bilateral hands and knees performed to evaluate other joints commonly affected by CPPD crystal deposition disease were negative. GEISINGER Health System

9. CASE REPORT Subsequently, patient underwent surgical resection and excisional biopsy of left TMJ mass, condylectomy, diskectomy, and total joint arthroplasty. The mass mimicked tophaceous gout intraoperatively. Pathology confirmed it to be CPPD crystal deposition disease of left TMJ mass, condyle and articular disc. Postoperatively patient did well and the left TMJ pain was resolved. GEISINGER Health System

10. Intra-operative picture of lesion prior to excision. PATHOLOGY Largest portion of the lesion status post excision

11. GEISINGER Health System 10X H&E of calcific deposits Pathology slides courtesy of Patrick Dorion, MD

12. GEISINGER Health System 40X of calcium pyrophosphate crystals with polarized light Pathology slides courtesy of Patrick Dorion, MD

13. GEISINGER Health System 40x of calcium pyrophosphate crystals with compensated polarized light Pathology slides courtesy of Patrick Dorion, MD

14. CALCIUM PYROPHOSPHATE DIHYDRATE (CPPD) CRYSTAL DEPOSITION DISEASE Metabolic disease where calcium pyrophosphate crystals deposited in synovial fluid result in calcification of articular cartilage, leading to acute arthritis in some patients. Predilection for joints with fibrocartilage: Knee, wrist, hip, shoulder, elbow. Identification of echogenic foci (crystals) in joint or soft tissues is diagnostic. 1.Löffler C, Sattler H, Peters L, Löffler U, Uppenkamp M, Bergner R. Distinguishing gouty arthritis from calcium pyrophosphate disease and other arthritides. J Rheumatol. 2015 Mar;42(3):513-20. doi: 10.3899/jrheum.140634. Epub 2014 Nov 15. PubMed PMID: 25399385. 2.Naqvi AH, Abraham JL, Kellman RM, Khurana KK. Calcium pyrophosphate dihydrate deposition disease (CPPD)/Pseudogout of the temporomandibular joint – FNA findings and microanalysis. Cytojournal. 2008 Apr 21;5:8. doi:10.1186/1742-6413-5-8. PubMed PMID: 18426573; PubMed Central PMCID: PMC2346483.

15. We describe the clinical and neuroimaging profile of unilateral monoarthritis of TMJ caused by CPPD crystal deposition disease. Early identification of this finding may orient clinicians in timely diagnosis and treatment. SUMMARY GEISINGER Health System