Septic Arthritis of Temporomandibular Joint Complicated with Castleman Disease

Posted By Arvinder Singh Harbaksh Singh
Septic Arthritis of Temporomandibular Joint Complicated with Castleman Disease

A 31 year-old Malay gentleman, with no underlying co-morbidities except for being an active smoker, initially presented to us in the year 2008 with complaints of pain and swelling at the right mandibular region for a duration of more than a year. The pain and swelling was over the right mandibular region was associated with pain and dysphagia. The patient had given history of seeking treatment from a private clinic but to no avail. An examination of the patient revealed a localized swelling at the right mandibular region that was tender on palpation and associated with trismus and pericoronitis of the right third molar tooth. A working diagnosis of a submasseteric abscess secondary to right third molar pericoronitis was made and a differential diagnosis of a mandibular tumour was also suspected. A Total White Blood Cell Count (TWBC) was done and it was reported as 8.0. He was admitted and given a course of intravenous Cefobid 1g twice daily (BD) and Metronidazole 500mg thrice daily (TDS). A CT scan was then done to further investigate the patient. The outcome of the investigation showed a rim enhancing lesion with air fluid level at the right mandibular region with erosion of the underlying bone (Figure 1). The swelling reduced as the oral antibiotic therapy was continued, however the pain persisted. The patient was then discharged with the medication of tablet Cefuroxime 500mg BD and tablet Metronidazole 500mg TDS upon discharge for 2 weeks and on follow up, the right mandibular condyle was not palpable with a notable deviation of the mouth to the right side. A radiograph was done and it showed erosion of the ramus of right mandible. A clinical diagnosis of osteomyelitis of right mandible was made and a CT scan was performed to review the disease progress. The scans was done within 2 months and it showed bony destruction of the right mandibular condyle and ramus with an aggressive right masticator space soft tissue lesion. The right submandibular lymph node was not enlarged during this time frame (Figure 2). An explorative surgery was then conducted. Intra-operatively, a soft tissue mass was seen distal to the right 3rd molar – this was curretted and sent for a histopathological examination. The report returned as non-specific showing mild to moderate infiltration of chronic inflammatory cells. The TWBC at this time was 7.2. The patient was continued on the prescribed oral antibiotics and requested to return for a follow-up, which he defaulted. In January 2010, the patient presented to the dental department with a complaint of pain and swelling at the right submandibular region associated with an upper respiratory tract infection. The pain at the right submandibular region was attributed to reactive lymphadenitis. He was prescribed with tablet Erythromycin Ethyl Succinate 400mg BD as outpatient. However the right submandibular swelling persisted and he was subsequently diagnosed with reactive lymphadenitis likely secondary to underlying ost

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