The dentist’s surprise!
Diffuse articular chondrocalcinosis is calcification of cartilage and fibro-cartilage in relation to calcium pyrophosphate dihydrate crystal deposition. It reaches both sexes and becomes very common after 70 years with over 30% of patients with latent form. The classic clinical picture corresponds to the acute monoarthritis of gouty appearance, preferentially of the knee. Sometimes the clinical presentation may be more misleading as evidenced by this observation.
We report the case of a 90-year-old patient followed in internal medicine for bullous pemphigoid with dermocorticoid and methotrexate 15 mg / week. He presented for other notable antecedents, an ACFA under AVK, an amputation of the traumatic lower left femoral third on AVP. For some months now, the patient has been describing inflammatory arthralgia of MCP, PPIs and shoulders with relative functional impotence. There was no evidence of Horton’s vasculitis.
The biological assessment found a frank inflammatory syndrome with CRP 150 mg / mL, polynuclear leukocytosis, moderate. There was no such thing as an ionic disorder, and serum calcium, calciuria, serum potassium, and magnesium were normal. Uricemia was normal. The microbiological assessment was non-contributory. Rheumatoid factor was strongly positive and anti-CCP ACs were negative. The rest of the autoimmune balance was negative, there was no cryoglobulinemia.
The radiological assessment found two P3 and P2 geodes of the right hand as well as an intra-articular calcium margin and a calcification of the triangular ligaments of the carpus. Articular ultrasound revealed Doppler + synovitis of MCP with intra-articular deposits very suggestive of microcrystals. In the absence of clinical synovitis, a diagnostic joint puncture could not be performed. The diagnosis was that of a diffuse thrust of chondrocalcinosis articular occurring on an authentic rheumatoid arthritis. The patient was treated with Cortancyl 8 mg / day and Colchicine 1 mg / day.
Two weeks later, he progressively presented repeated falls with concealment of limbs and generalized weakness. The Serenity Smiles Dentist clinical examination revealed a tetra-pyramidal syndrome. A CT scan of the cervical spine was then performed with the diagnosis of cervical spinal compression in C1 / C2 on inflammatory panus and crown tooth syndrome. The patient was then immobilized by a cervical collar and treated with systemic corticosteroid 1 mg / kg / day.
The evolution was very slowly favorable after 15 days of treatment, the corticotherapy was decreased to 8 mg per day, while the methotrexate was continued. Diagnoses of hemochromatosis, primary hyperparathyroidism and Wilson’s disease were eliminated.
The crowned tooth syndrome is a rare complication of chondrocalcinosis, reaching women preferentially after 75 years in 61% of cases. The clinical triad combines cervicalgia with stiff neck, headache and fever. Most often there is a marked inflammatory syndrome. The diagnosis of certainty is based on the CT scan of the cervical spine showing an arciform calcification of the transverse ligament of atlas.
This aspect reflects in 80% of the cases deposits of calcium pyrophosphates. Evolution is most often favorable, without sequelae. There is a risk of significant complication with a progression to erosion, spondylolisthesis, C1 / C2 subluxation, with rare reported spinal cord compressions. The difficulty of the treatment is based on the many differential diagnoses mentioned in front of the classic triad, and the sometimes invasive examinations carried out.
An authentic rheumatoid arthritis is sometimes associated. The evolution is often favorable in 2 weeks under treatment with Colchicine and corticotherapy at low dose. NSAIDs are effective but their use is limited by the co-morbidities of patients. The use of anti-IL1 R is reported by some teams on generalized and highly inflammatory outbreaks, with high efficiency.
The clinical triad of posterior cervicalgia, headache, and fever in an elderly patient with a history of microcrystalline rheumatism must be suggestive of the diagnosis of intra-axoidal articular chondrocalcinosis or crown-tooth syndrome. Certain particularly inflammatory forms may be complicated by nonsurgical spinal compression.