Jaw Pain Research Articles

Septic arthritis of the temporomandibular joint: a systematic review

Introduction: This study aimed to describe the history, clinical presentation, laboratory examination, treatment, and long-term functional characteristics of patients with septic arthritis of the temporomandibular joint (SATMJ). Methods: All articles in the English literature on SATMJ were queried using PubMed, Science Direct, and Google Scholar (2013 to 8 March 2023), and the keywords "temporomandibular OR TMJ AND septic arthritis". Articles are included if related to the SATMJ in patients of all ages, using case reports, case series, and cohort studies. The Newcastle-Ottawa Scale was applied to all included investigations. Article selection followed PRISMA’s guidelines for measuring the quality of systematic reviews. Results: A preliminary literature search yielded 220 results, of which 25 matched the inclusion requirements, and one more came via reference checking. There were 25 cases with a mean age of 26.7 years (0.1 to 85). Symptoms mainly consisted of TMJ/preauricular pain (n=17, 42.5%), trismus (n=20, 50%), and facial/preauricular swelling (n=24, 60%). Most patients had no systemic symptoms (n=16, 40%). The average mouth opening measured 16.3 mm (5 to 36). The diagnosis was made using the following imaging techniques: X-ray (n=6, 15%), CT scan (n=33, 82.5%), MRI (n=16, 40%), and ultrasound (n=1, 2.5%). Staphylococcus aureus (n = 10, 25%) was the most frequently isolated. Approximately 40 patients (100%) received antibiotics, 26 (65%) patients underwent surgery (e.g., joint aspiration, arthroscopy, etc.), of which two patients (5%) required further surgical intervention. In general, long-term results were positive. In 10 of the 40 patients (25%) who had documented follow-up, sequelae occurred. Conclusion: In the event of trismus, jaw pain, or preauricular edema, SATMJ should be considered. Quick examination and broad-spectrum antibiotic treatment are part of management. Although surgery is not always necessary, it can be life-saving in serious circumstances.

Tongue Tie and Management of Two Siblings: A Review with Report

Ankyloglossia is defined as a developmental anomaly of the tongue characterized by an abnormally short, thick lingual frenulum resulting in limitation of tongue movement or in simple terms, tongue tie. In this condition there is difficulty lifting the tongue to the upper teeth or moving the tongue from side to side, tongue appears notched or heart shaped when stuck out. Adult tongue-tie may result in mouth breathing, inability to speak clearly, difficulty kissing, jaw pain and tongue thrust. We hereby report case of tongue-tie of two siblings and its management by electrocautery, this technique was simple, easier as well as less time consuming, unlike conventional surgery. There is little damage to adjacent tissue and no blood in the operating field when using the electrocautery.

Clinical manifestation and microbial profiling of recurrent MDR microorganisms associated with head and neck infection- a retrospective study

Head and neck infection (HNI) can lead to life-threatening complications, including death. The purpose of this study is to look at the entire clinico-demographic profile of patients with HNI as well as the microbiologic profile of recurring bacterial infection cases with a variety of symptoms. A retrospective cross-sectional study was conducted on 1080 HNI patients in a tertiary care hospital in Bhubaneswar, Odisha, India, from January 2018 to December 2022. Of the 1080 cases, 771 (71.39%) were males, 309 (28.61%) were females, and 603 (55.83%) were from rural areas reporting to a tertiary care hospital. 62% of the cases were between the ages of 31 and 60. Neck abscesses account for 570 (52.78%) of all cases, with parotid abscesses accounting for 233 (21.57%), peritonsillar abscesses accounting for 170 (15.74%), otitis media 32 (2.96%), and oral cavity infection accounting for 26 (2.41%). In 854 (79.07%) cases, the etiology was odontogenic, followed by sinus in 188 (17.41%) and otogenic in 38 (3.52%). The most common presenting features were neck swelling in 537 (49.72%) cases and face swelling in 238 (22.04%) cases, followed by jaw pain in 26 (2.41%) cases and others. Patients were hospitalized for an average of 11.824.38 days. Treatment and recurrence had a strong significant relationship (p 0.001). Microbiologic investigation of recurrent patients revealed 12 microorganisms, including bacteria and fungus, mainly multidrug-resistant in given ascending order Staphylococcus aureus (26.74%), Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii, Escherichia coli, Candida albicans (4.65%), Aspergillus fumigatus, A. flavus, A. niger, C. tropicalis, C. glabrata, C. krusei. Apart from colistin, almost all antibiotics were highly resistant to gram-negative bacteria, whereas against S. aureus, benzylpenicillin, and oxacillin showed 100% resistance, followed by erythromycin (91.3%), levofloxacin (86.96%), and ciprofloxacin (82.61%). This exploratory study would aid in determining the HNI burden and epidemiology, as well as their treatment status.

Zoledronate-Induced Large Vessel Vasculitis Diagnosed by PET/CT

Bisphosphonates remain a first-line treatment for osteoporosis. The most-widely used is zoledronate, which is well tolerated by most patients, but may rarely cause acute inflammatory reactions, which resemble those of large vessel vasculitis (LVV). We report a third case of LVV associated with zoledronic acid infusion, presenting with a 2-week history of fever up to 40 °C, flu-like symptoms, left jaw pain, myalgia, arthralgia, ankle stiffness in the morning, and intermittent claudication, diagnosed by the hybrid imaging modality 18F-FDG PET/CT with isolated lower extremity involvement and successfully treated with glucocorticoids.

A Case Report of Refractory Postherpetic Neuralgia After Ramsay Hunt Syndrome Treated With Tympanic Nerve Neurectomy.

Ramsay Hunt syndrome is a facial nerve palsy that arises from herpes zoster infection. In rare cases, postherpetic neuralgia is a complication following Ramsay Hunt syndrome. Pain management to address postherpetic neuralgia includes facial nerve blocks, medications such as gabapentin, carbamazepine and botulinum toxin injections, and pulsed radiofrequency. Despite the reported benefits for patients with glossopharyngeal nerve pain, neurectomy as a treatment has rarely been described. A 45-year-old patient visited our ENT clinic for chronic right-sided facial, ear, and jaw pain that persisted for 9 years following the development of Ramsay Hunt syndrome. She trialed multiple medications including gabapentin, carbamazepine, and botulinum toxin injections with minimal relief to her symptoms. The patient underwent a diagnostic myringotomy with topical application of lidocaine to the tympanic nerve. This resulted in temporary relief of her pain until the effects of the lidocaine subsided. The patient was subsequently offered lysis of the right tympanic nerve for more definitive management. The patient experienced significant pain reduction after the right tympanic neurectomy procedure. Chronic postherpetic neuralgia following Ramsay Hunt syndrome can cause significant impairment in a patient's quality of life. For patients with ear pain refractory to conservative management, a tympanic neurectomy can be considered.

Physiotherapy for pain, jaw mobility, and oral health-related quality of life in patient with trismus following radiation therapy for jaw cancer: A case report

Background: Trismus is a painful condition that restricts the temporomandibular joint range of motion (ROM) causing difficulty in eating, chewing, speaking, etc., affecting the oral health-related quality of life (OHRQOL). It often presents as a complication during pre-malignancy stage or after oral cancer treatment. Its prevalence is between 28% and 79%, and it is 8 times more common in edentulous patients. Case Presentation: The 57-year-old male complained of continuous tongue and jaw pain with difficulty in chewing, eating, and speaking 1 year before and gradually developed small ulcers over the right jaw. After complete investigation, the patient was diagnosed with jaw cancer and underwent radiotherapy for 2 months. This patient came with complaints of pain, difficulty in mouth opening to physiotherapy department, 3 months following radiotherapy, diagnosed as a case of trismus. A comprehensive physiotherapy protocol including LASER, mobilization, Myofascial release, active exercises for the period of 4 weeks was given. Outcomes for pain, jaw mobility, and OHRQOL were evaluated at baseline and 4 weeks. Conclusion: Four weeks of comprehensive physiotherapy protocol was found effective in reducing pain and improving jaw mobility and OHRQOL in patients with trismus following radiation therapy.

Anti-MOG antibody optic neuritis in AML – A case report

We report a unique presentation of anti-myelin oligodendrocyte (MOG) optic neuritis in a patient with AML in remission. An elderly man presented with diminished vision in the right eye associated with headache and jaw pain. Systemic investigations revealed no leukemic recurrence. The presence of anti-MOG antibodies and optic nerve enhancement suggested of unilateral optic neuritis. Steroid therapy resulted in the resolution of disc edema. We faced a diagnostic dilemma in a patient with unilateral disc edema in the background of multiple systemic diseases. A methodical approach to investigations helped us in accurate diagnosis, institution of prompt therapy, and minimizing visual morbidity. We present this case to highlight the importance of differentiating leukemic optic nerve infiltration from other causes of unilateral disc edema, as their therapeutic approaches are different.

Lymphoma masquerading as jaw pain, headache, and syncope: A case report

BackgroundLymphomas of parapharyngeal space often have complex manifestations, posing a diagnostic dilemma for clinicians. Case DescriptionA 64-year-old man sought treatment for a 4-month history of unresolving right-sided headache and jaw pain associated with syncope, all of which started with a toothache. Since the onset of pain, the patient had undergone multiple diagnostic tests with various specialists, with no pain relief. A detailed clinical and radiologic examination by an orofacial pain specialist revealed diffuse large B-cell lymphoma in the parapharynx. Practical ImplicationsA thorough knowledge of the head and neck anatomy helps in identifying the pathophysiology of complex orofacial pain manifestations, which assists in early diagnosis and treatment.

Oral appliance influence on jaw function in obstructive sleep apnea

Oral appliance (OA) therapy in obstructive sleep apnea (OSA) could be a risk factor for normal jaw function, given the prolonged effect of an OA in keeping the mandible in a protruded position away from a normal position. This study aimed to assess changes in symptoms and clinical findings related to jaw function after 1 year of treating OSA with an OA. In this follow-up clinical trial, 302 patients with OSA were assigned to treatment with either monobloc or bibloc OA. Baseline and 1-year follow-up assessment included using the Jaw Functional Limitation Scale, self-reported symptoms and signs related to jaw function. The clinical examination of jaw function included mandibular mobility, dental occlusion, and tenderness in the temporomandibular joints and masticatory muscles. Descriptive analyses of variables are presented for the per-protocol population. To evaluate differences between the baseline and the 1-year follow-up, paired Student t tests and the McNemar change test was used. One-hundred and ninety-two patients completed the 1-year follow-up (male 73%, mean aged 55 ± 11 years). There was no change in the Jaw Functional Limitation Scale score at the follow-up (nonsignificant). The patients described no change in symptoms at the follow-up, except for improvements in morning headache (P<0.001) and increased frequency of difficulties in opening the mouth or chewing on awakening (P= 0.002). Subjectively reported changes in dental occlusion during biting/chewing increased significantly at the follow-up (P= 0.009). No changes in measurements of jaw mobility, dental occlusion, or pain on palpation of the temporomandibular joints or masticatory muscles were seen at the follow-up. Thus, using an OA in treating OSA had limited influence on jaw functions and related symptoms. Moreover, the risk of developing pain and functional impairment in the masticatory system was infrequent, indicating that this treatment is safe and can be recommended.

EXTENSIVE MANDIBULAR LESION AS A PRIMARY SIGN OF NEOPLASM OF PLASMA CELL ORIGIN: A CASE REPORT

A 57-year-old woman complained of jaw pain and presented no swelling on intraoral examination. Imaging examinations showed extensive osteolytic lesions throughout the mandible with signs of manifestation in the maxilla, including the involvement of other bones. Computed tomography revealed several hypodense osteolytic areas with cortical disruption in the left lingual posterior region of the mandible. Moreover, the incisional biopsy showed diffuse and monotonous layers of plasmacytoid cells with different degrees of differentiation. Immunohistochemical analysis showed positivity in plasmacytoid cells for anti-kappa, CD138, MUM1, and CD79a antibodies, and negative results for anti-lambda and CD20. The diagnosis of multiple myeloma was confirmed based on the histopathological and immunohistochemical data along with the imaging finding of diffuse lytic lesions. The patient was referred for further examinations and treatment. She remained under follow-up for six months after the biopsy and manifested a pathological fracture of the left clavicle, probably related to the underlying disease. A 57-year-old woman complained of jaw pain and presented no swelling on intraoral examination. Imaging examinations showed extensive osteolytic lesions throughout the mandible with signs of manifestation in the maxilla, including the involvement of other bones. Computed tomography revealed several hypodense osteolytic areas with cortical disruption in the left lingual posterior region of the mandible. Moreover, the incisional biopsy showed diffuse and monotonous layers of plasmacytoid cells with different degrees of differentiation. Immunohistochemical analysis showed positivity in plasmacytoid cells for anti-kappa, CD138, MUM1, and CD79a antibodies, and negative results for anti-lambda and CD20. The diagnosis of multiple myeloma was confirmed based on the histopathological and immunohistochemical data along with the imaging finding of diffuse lytic lesions. The patient was referred for further examinations and treatment. She remained under follow-up for six months after the biopsy and manifested a pathological fracture of the left clavicle, probably related to the underlying disease.

A Curious Case of Jaw Swelling due to Precursor B Cell Acute Lymphoblastic Leukemia

ABSTRACT Acute lymphoblastic leukemia (ALL) is a rare leukemia in adults but is the most common type in children. We present a case of a 40-year-old female presenting with jaw pain and swelling with fever which appeared to be an abscess. Further evaluation revealed the presence of blast cells in the peripheral blood smear. Flow cytometry was performed which further revealed pre-B cell ALL. It underwent spontaneous tumor lysis and despite all the resuscitative measures, she succumbed to sepsis and multiorgan dysfunction. The purpose of this report is to document an unusual manifestation of an adult B cell acute lymphoblastic leukemia (ALL) presenting as a jaw mass masquerading as an abscess undergoing spontaneous tumor lysis.

COVID-19 induced remission of biliary and renal cell carcinomas.

e14598 Background: Clear cell renal carcinoma and cholangiocarcinoma are resistant to standard therapy. Complete remissions are rare. SARS-CoV-2 (COVID-19) boosts anti-viral immune responses but effects on cancers are unknown. Case reports of hematologic cancer remissions after COVID infection are emerging. Anti PD1/PD-L1 antibody therapy have prolonged remission in 20% of solid tumor patients. mRNA COVID-19 vaccines and COVID-19 active infections create anti-viral immune responses - increased IgG titers, SARS-CoV-2-specific antibodies, and boost T-cell response. Anti PD-1/PD-L1 antibodies immune responses, are presumed independent of the immune response to COVID vaccination/infection. Two previous case reports of hematologic remission were seen after COVID infection. (Hodgkins, multiple myeloma). There are no cases of solid cancer remission after COVID-19 exposure. Methods: Three patients with solid cancers and complete/near complete radiographic remissions after COVID-19 exposure. Two on low carbohydrate diets. History, dietary course and clinical outcomes are presented. Results: Case 1: 58 year old male diagnosed with stage IV clear cell renal carcinoma (lung nodules, mediastinal nodes). After 5 years he progressed on Sunitinib and began Nivolumab. His cancer stabilized but hypophysitis, diarrhea, severe jaw pain ended his treatment. After COVID-19 booster vaccine, he became anorexic, lost 50 lbs over 8 weeks (267 to 211 lb). Relapse was suspected but PET CT showed complete resolution of his lung nodules and adenopathy. Asymptomatic and in remission over 9 months post vaccine. Case 2: 51 year old male heavily pretreated stage 4 renal cell cancer, bone, liver, nodal metastases. On Nivolumab with stable disease but after COVID booster vaccine had high fever, fatigue, myalgia. PET CT scans later showed near complete resolution of his bony, hepatic and nodal metastatic sites. Case 3: 75 year old male with unresectable cholangiocarcinoma on second line Atezolizumab. COVID-19 infection was followed by complete radiographic remission. Conclusions: Effects of SARS-CoV-2 (COVID-19) on cancers remain unknown. Few case reports of cancer remissions after infections are emerging. These are two cases of renal cell cancers in complete remission after COVID-19 vaccination while on immunotherapy. Both followed low glycemic diets. Third case was a complete remission of biliary cancer after an acute COVID-19 infection. Proposed anti-cancer mechanisms - pathogen specific T cell action, anti-inflammatory effects against COVID-19 infection, cross-reactivity against tumor antigens, natural killer cell activation. COVID-19 proteins have oncolytic properties - HIV related B cell apoptosis and Coxsackievirus A21 oncolytic effects on myeloma and CD138+ plasma cells via intercellular adhesion molecule interaction. COVID-19’s effects plus the anti PD-1/PD-L1 antibodies immune response may be synergistic and merits further research.

1033 The link between vision loss and sleep

Abstract Introduction Non-arteritic ischemic optic neuropathy (NAION) is the most common optic nerve disorder among patients over the age of 50. Several risk factors have been associated with NAION including systemic hypertension, diabetes mellitus, advanced age, and certain optic disc morphologies. A significant association between obstructive sleep apnea (OSA) and NAION has also been reported. Here, we present a case of a middle-aged man with a recent diagnosis of NAION who was subsequently found to have OSA. Report of case(s) A 53-year-old man with a remote history of head injury with concussion and tobacco use was referred to the Sleep Medicine Clinic from Ophthalmology for evaluation of obstructive sleep apnea (OSA). The patient initially presented to Ophthalmology due to acute onset, painless, left-sided, inferior vision loss. The patient was otherwise healthy and denied a history of diabetes mellitus or hypertension. He did report alcohol and cigar use on the night prior to the acute onset vision loss. He denied fevers, chills, joint or jaw pain, scalp tenderness, or jaw claudication. On initial evaluation he was found to have significant left eye optic disc edema. Blood test revealed normal complete blood count (CBC), erythrocyte sedimentation rate (ESR), and C-Reactive protein (CRP). His orbit and brain magnetic resonance imaging with and without contrast revealed no significant findings. He was subsequently diagnosed with left NAION. Further review of symptoms was positive for snoring, dry mouth, nighttime awakenings, and unrefreshing sleep, concerning for OSA and leading to referral to our Sleep Medicine Clinic. During initial consultation in Sleep Medicine, he denied symptoms concerning for any other sleep disorders. He subsequently underwent a home sleep test (WatchPAT) which confirmed the diagnosis of OSA. The apnea-hypopnea index (AHI) was 7.9 and the lowest oxygen saturation was 88%. Conclusion Given the reported association between NAION and OSA, a careful history should be obtained to screen for OSA when NAION is diagnosed. Support (if any)

Associations between temporomandibular disorders, pain, jaw and masticatory function in dentofacial deformity patients: A cross-sectional study.

Patients with dentofacial deformity often present with impaired masticatory function, orofacial pain and temporomandibular disorders (TMD). This study investigates the relationship between TMD, pain, jaw and masticatory function at different stages of orthognathic surgical (OS) treatment. A total of 120 OS patients were prospectively recruited and grouped as pre-orthodontic (group 1), pre-surgery (group 2), 4-month post-surgery (group 3), 24-month post-surgery (group 4), in addition to 30 controls (group 0). Outcomes were assessed using: Jaw Function Limitation Scale (JFLS), McGill pain questionnaire, DC/TMD instrument, voluntary maximum bite force (MVBF), and masticatory efficiency (ME) using two-coloured chewing gum. Data were analysed using structural equation modelling. The prevalence of non-painful TMD did not differ between groups (p = .827). However, the prevalence of painful TMD differed between groups (p = .001). Among the painful TMDs, the highest prevalence was observed for masseter myalgia in group 2 (p = .031), and importantly group 4 did not differ from group 0 (p = .948). The MPQ score was significantly higher in group 1 (p = .001) compared to group 0, and the JFLS score was significantly higher in groups 1, 2 and 3 compared to group 0. Notably, MPQ (p = .756) and JFLS (p = .572) scores in group 4 were not different from group 0. However, MVBF (p = .996) and ME (p = .991) did not differ between groups 1 and 4. The association of self-reported pain and jaw function with the masticatory function was observed in OS patients. OS was not associated with a negative impact on TMD. Jaw function and pain levels were similar to controls at the 24-month follow-up. The masticatory function was further affected by the surgery and seems to require a longer recovery time. Moreover, it was confirmed that pain and TMD were associated with limitations in jaw function and impacts on masticatory function.

Children’s Experiences Using Various Appliances for Class II Malocclusion: A Cross-sectional Study

Abstract Background: Skeletal Class II correction is one of the most challenging malocclusions for a dental surgeon. The appliances used in their treatment have advantages and disadvantages regarding patient comfort. Therefore, the aim of this study was to evaluate the experiences of patients regarding the use of various removable appliances for Class II malocclusion. Methodology: Patients were divided into three groups regarding the type of orthopaedic appliance used, i.e. headgear, twin block and a combination of twin block with headgear. The subjects were given a questionnaire which consisted of 15 multiple-choice questions. The children answered the questions in a one-to-one session with the principal investigator in the presence of their parents. The data were collected and descriptive statistics were done, and P &lt; 0.05 was considered statistically significant. Results: Out of 75 patients, 49 were undergoing treatment with headgear, 14 with twin block and 12 with a combination of twin block and headgear. Amongst these patients, toothache was observed in all patient groups. Pain in temporomandibular joint (TMJ) was found to be statistically significant (P = 0.0397) in subjects using twin block and twin block with headgear. Patients had difficulties during sleeping and speech also. Conclusion: This study has shown that pain of the teeth, jaw pain and sleep difficulties were the common problems encountered while using the appliances. The study also showed that patients had problems with pronunciation. TMJ pain was significant in patients using twin block and twin block with headgear.

Impact of dental fluorosis on the oral health related quality of life of adolescents in an endemic area.

Oral diseases and conditions affect the physical, social, and psychological well-being of an individual. The aim of this study was to determine the association between the severity of dental fluorosis and oral health related quality of life (OHRQoL) among 15-year-old school children residing in an endemic area for dental fluorosis in Sri Lanka. A cross-sectional study was conducted among 989, 15-year-old school children who were lifetime residents of Kurunegala district. A validated Sinhala version of the Child Perception Questionnaire (CPQ 11-14) was used to assess OHRQoL. Dental fluorosis was assessed using the Thylstrup and Ferjeskov index (TF index) while dental caries and malocclusion were assessed using the WHO Basic Methods and Dental Aesthetics Index (DAI) respectively. In addition, information pertaining to parental level of education, type of toothpaste used, frequency of toothbrushing and use of dental services was also gathered. The prevalence of dental fluorosis was 52%. The overall prevalence of impacts based on the CPQ was 38.2%. The severity of dental fluorosis was not significantly associated with the overall prevalence of impacts. However, the severity of dental fluorosis was significantly associated with three oral impacts namely "having pain in teeth, lips, jaws, or mouth", "felt irritable or frustrated" and "other children teased or called names". According to the multiple logistic regression analysis, use of dental services and moderate to severe malocclusion were significantly associated with poor OHRQoL but not dental fluorosis. The severity of dental fluorosis was not associated with OHRQoL of the participants.

Abstract #1405323: A Rare Case of Multiple Fragility Fractures Caused by Tumor-Induced Osteomalacia

Tumor-induced osteomalacia (TIO) is a rarely encountered paraneoplastic syndrome caused by a small, usually benign tumor of mesenchymal origin. It can present with severe hypophosphatemia and osteomalacia, usually in adulthood, but also in adolescence. The rarity of these tumors often leads to a late or missed diagnosis. Here we present a case of TIO with missed diagnosis for many years, which as a result, presented with multiple fractures. A 54-year-old Asian woman presented to the emergency department with complaints of progressive lower back pain, weakness, and chronic myalgias. Imaging revealed diffuse osteoporosis, multiple rib and pelvic fractures, and bilateral coxa vera. Labs revealed normal corrected serum calcium 9.0 mg/dl (8.7-10.5), high PTH 144.9 mg/ml (9-77), low serum phosphorus 1.1 mg/dl (2.5-4.9), high alkaline phosphatase 474 u/ml (55-135), and normal 25-hydroxyvitamin D (25 Vit D) 45.8 ng/ml (30-100). Further labs showed high urinary phosphorus >90 mg/dl and low serum 1,25-Dihydroxyvitamin D (1,25 Vit D) 18 pg/ml (20-79). Genetic testing for hypophosphatemic rickets was negative. Serum fibroblast growth factor 23 (FGF23) level was found to be elevated to 218 pg/ml (< 59). She was later found to have a left mandibular fracture. A 68Ga-DOTATATE PET/CT scan revealed gastric wall thickening. Several months after her initial presentation she reported ongoing left jaw pain and an enlarging left mandibular mass. Repeat PET scan revealed a hypermetabolic mandibular lesion. Pathologic analysis of the biopsied lesion was consistent with a phosphaturic mesenchymal tumor, and the lesion was resected. Labs three months following tumor resection revealed normalization of serum phosphorus, 1,25 Vit D, and PTH. TIO is caused by overproduction of FGF23 and other phosphaturic proteins by a mesenchymal tumor. High serum FGF23 causes decreased renal phosphate reabsorption and increased 1,25 vit D production. This results in development of rickets/osteomalacia. These tumors are usually benign, small, slow growing neoplasms making them difficult to diagnose. Delay in diagnosis can result in complications such as fractures. TIO, although rare, should be on the differential for patients with hypophosphatemia and progressive osteopenia. Analysis of serum 1,25 vit D, FGF23, and urine phosphorous levels is indicated, followed by tumor localization with PET/CT, CT, or MRI. Tumor resection is often curative, as in this case. Increased awareness of this condition may help to reduce the proportion of missed TIO cases and improve outcomes in recognized cases via earlier recognition and treatment.

Lemierre syndrome associated Cavernous Sinus Thrombosis and Development of Internal Carotid Artery Narrowing: A Case Report and Review of Literature (P2-5.005)

<h3>Objective:</h3> To report a case of Lemierre syndrome complicated by cavernous sinus thrombosis (CST) and bilateral internal carotid artery (ICA) stenosis without cerebral infarction in a young woman and summarize the literature on Lemierre syndrome with arterial involvement. <h3>Background:</h3> Lemierre syndrome is a complication of oropharyngeal infection characterized by thrombosis of the internal jugular vein (IJV) with septic thrombophlebitis followed by bacteremia and septic emboli dissemination to distal organs, but arterial involvement is extremely rare. <h3>Design/Methods:</h3> A 24-year-old previously healthy woman presented to the hospital with one week of progressive jaw pain and neck swelling after recent tooth extraction. Physical examination showed left ptosis without other neurologic deficits. Computer tomography (CT) of the neck found multiple anterior neck abscesses. The patient underwent emergent incision and drainage of abscess at the left lateral pharyngeal, left masticator, and bilateral sublingual space. Vascular imaging revealed findings of non-occlusive thrombus in the left IJV, bilateral cavernous sinus thrombosis (CST), and septic emboli in bilateral apical lungs, consistent with Lemierre syndrome. Neuroimaging showed no cerebral infarction even though a digital subtraction angiogram (DSA) demonstrated bilateral ICA severe stenosis (&gt;70%) in both extracranial and intracranial segments. Cultures of abscess samples proved positive for <i>Candida albicans</i> and <i>Streptococcus constellatus</i>. The patient received treatment with full-coverage antibiotics and anticoagulation therapy resulting in an excellent outcome. <h3>Results:</h3> A literature search yielded 29 cases of Lemierre syndrome with arterial complications, which manifested as ICA occlusion or stenosis, or mycotic aneurysm development. Despite variable clinical symptoms, most patients developed CST and were all treated with antibiotics. Anticoagulation therapy is controversial given scarce and inconsistent evidence. <h3>Conclusions:</h3> The presented case and literature review emphasize the variability of the clinical course of Lemierre syndrome. Septic CST can be a rare cause of ICA occlusion, stenosis, or pseudoaneurysms because of arteritis, and thus expedited workup is necessary. <b>Disclosure:</b> Dr. Zhou has nothing to disclose. Dr. Malik has nothing to disclose.

OA32 Jaw claudication - does the textbook description need updating?

Abstract Background/Aims Recognition of jaw claudication is crucial to expedite diagnosis and treatment of giant cell arteritis (GCA). The ACR 1990 criteria defined claudication of the jaw, tongue or deglutition as “development or worsening of fatigue or discomfort in muscles of mastication, tongue, or swallowing muscles while eating”. We sought to describe the diverse ways in which patients may describe this key GCA symptom and its impact on health-related quality of life. Methods Secondary analysis of a qualitative dataset originally created for the development of a patient-reported outcome measure for GCA. Participants (n = 36) with GCA confirmed by biopsy/imaging were recruited using purposive sampling from two rheumatology clinics and one ophthalmology clinic in the UK (n = 25) and Australia (n = 11). Interviews transcripts from the original study were organised within QSR NVivo 12 software and analysed using template analysis. Themes were refined through discussion among researchers including a patient partner. Results 20 of 36 participants (56%) reported jaw symptoms. Of these 20, the median age was 76.5 years; 60% were female. Five main themes were identified in the data: physical sensations; impact on function; impact on diet; symptom response to steroids; attribution to other causes (see Table 1). Whilst a large proportion of patients described jaw pain, jaw cramp, jaw stiffness and lockjaw had also been described. Symptom resolution following commencement of steroids varied among participants. Jaw symptom was misjudged as due to dental cavity, ear infection and teeth grinding by healthcare professionals in some cases. Some patients did not seek immediate help from healthcare professionals regarding their jaw symptoms as they were thought to be related to arthritis, age or viral illnesses. Conclusion Patients with GCA described their jaw symptoms in various ways, not exclusive to chewing. When Horton originally described jaw claudication, he also observed that some patients reported ‘lockjaw’. For early recognition and prompt diagnosis of GCA, we suggest that textbooks and teaching should be updated to reflect this. Patient education on the potential significance of jaw symptoms is also crucial to avoid delay in seeking help. Disclosure J. Lim: None. E. Dures: None. L. Bailey: None. C. Almeida: None. C. Ruediger: None. C. Hill: None. J. Robson: None. S.L. Mackie: Consultancies; Roche/Chugai, Sanofi, AbbVie, AstraZeneca. Other; SLM has given talks on behalf of her institution for Pfizer, Vifor and UCB. In all cases fees were paid to her institution and no personal fees were received, SLM was supported by Roche to attend EULAR2019 and by Pfizer to attend ACR2021 virtually, SLM has been an investigator on clinical trials for Sanofi and GSK, As a research grant co-applicant, SLM has received research funding (partial salary support) from Vifor, paid to her institution.

Myocardial Infarction Signs and Symptoms: Females vs. Males.

Cardiovascular disease is the number one killer of females in the United States today, and myocardial infarction (MI) plays a role in many of these deaths. Females also present with more "atypical" symptoms than males and appear to have differences in pathophysiology underlying their MIs. Despite both differences in symptomology and pathophysiology being present in females versus males, a possible link between the two has not been studied extensively. In this systematic review, we analyzed studies examining differences in symptoms and pathophysiology of MI in females and males and evaluated possible links between the two. A search was performed for sex differences in MI in the databases PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature) Complete, Biomedical Reference Collection: Comprehensive, Jisc Library Hub Discover, and Web of Science. Seventy-four articles were ultimately included in this systematic review. Typical symptoms for both ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) such as chest, arm, or jaw pain were more common in both sexes, but females presented on average with more atypical symptoms such as nausea, vomiting, and shortness of breath. Females with MI also presented with more prodromal symptoms such as fatigue in days leading up to MI, had longer delays in presentation to the hospital after symptom onset, and were older with more comorbidities than males. Males on the other hand were more likely to have a silent or unrecognized MI, which concurs with their overall higher rate of MI. As they age, females have a decrease in antioxidative metabolites and worsened cardiac autonomic function than male. In addition, at all ages, females have less atherosclerotic burden than mles, have higher rates of MI not related to plaque rupture or erosion, and have increased microvasculature resistance when they have an MI. It has been proposed that this physiological difference is etiologic for the male-female difference in symptoms, but this has not been studied directly and is a promising area of future research. It is also possible that differences in pain tolerance between males and females may play a role in differing symptom recognition, but this has only been studied one time where females with higher pain thresholds were more likely to have unrecognized MI. Again, this is a promising area for future study for the early detection of MI. Finally, differences in symptoms for patients with different atherosclerotic burden and for patients with MI due to a cause other than plaque rupture or erosion has not been studied and are both promising avenues to improve detection and patient care in the future.