Not all odontoid is rheumatoid
Dr Sharon Cowley Dr Shawn Chavrimootoo Dr Sekharipuram Ramakrishnan
Regional Department of Rheumatology, Navan
Precipitation of crystals of calcium pyrophosphate dihydrate in connective tissues is associated with several clinical syndromes including acute inflammatory arthritis, degenerative chronic arthropathies and subclinical radiographic abnormalities.
A 76 year old lady presented to ED with a four day history of left knee swelling and left sided neck pain. She attended her GP and was prescribed coamoxyclav 625mg TDS and solpadeine 8/30/500mg two tablets QDS. She then developed diarrhoea, vomiting and reduced oral intake. Energy was reduced and she was unable to mobilise secondary to gereralised weakness. She was seen on a GP house call one week after initial consultation and was then referred to the emergency department.
Left knee swelling occurred spontaneously in the absence of trauma, 6/10 severity with associated stiffness. Left sided neck pain radiated to the left post auricular region, 10/10 severity with no associated headache, jaw claudication or visual disturbance. She denied temperatures, rashes or any other joint pain. Her background history included hypertension, hiatus hernia, B12 deficiency, cholecystectomy, and asthma. Her medications on admission included ramipril 5mg OD, indapamide SR 1.5mg OD, esomeprazole 40mg OD, calcichew tablet OD, B12 injections weekly, relvar ellipta inhaler 92/22mcg OD, denosumab 60mg 6 monthly.
Bloods on admission were unremarkable apart from a c-reactive protein of 109.7mg/l, ferritin of 567ng/ml. X-rays were completed to evaluate her neck and knee pain. Bilateral knee xrays showed mild degenerative change and chondrocalcinosis. X-ray of the cervical spine showed degenerative changes in the facet joints in the mid cervical spine.
The patient deteriorated with spiking fevers, crp rise to >300 and increasing neck pain and tenderness over C1-C2. She was reviewed by orthopaedics who recommended IV antibiotics for presumed discitis. She had an MRI spine which showed oedema and erosion of the odontoid, appearances suggestive of rheumatoid arthritis. CT was subsequently performed showing calcification of the alar ligament with arthropathy and erosive change most compatible with CPPD disease.
This case highlights the varied presentation of CPPD disease. Spinal CPPD disease is often overlooked. Radiology was particularly helpful in the final diagnosis.