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TMJ Symptoms with Acute Lymphocytic Leukemia:

A Case Report

Author: Joseph DiDonato, III, DDS, MBA, FAGD

Often, in clinical practice, patients will papillomavirus, hepatocellular carcino- Human T-cell leukemia virus type 1 (HTLV-
present with vague symptoms for which a ma- hepatitis virus, and adult T-cell leuke- 1) is a retrovirus that infects 20 million peo-
cause can not be identified. The patient may mia-lymphoma (ATL)- human T-cell leuke- ple worldwide and it was the first retrovirus
be a poor historian or the symptoms may be mia virus type 1 (HTLV-1). to be found to cause human cancer, adult
poorly expressed. In these cases attempt- T-cell leukemia (ATL) . Because it is a
3
ing to obtain an answer, or even a complete Adult T-cell leukemia-lymphoma (ATL) is retrovirus, its RNA must first be translated
history, during a typical hygiene exam can a sub-category of acute lymphoblastic leu- into DNA and then incorporated into the
be frustrating, especially if the routine ra- kemia (ALL). It is a rare form of leukemia host cell DNA where it can replicate along

diographs and clinical findings are negative. in which too many bone marrow stem cells with the host cell lineage. The virus does
However, in a small percentage of cases, become white blood cells- lymphoblasts. not replicate simply by producing virons
valuable clues are present to indicate the (Figure 1) These lymphoblasts do not fight that infect cells. Instead, the infectivity of
need for further evaluation. HTLV-1 is mediated through a com-
plex oncoprotein, called Tax, that
The presentation of episod- is needed to start the cellular trans-
ic discomfort in one or both formation. Once inside the cell the
temporomandibular joints is integrated virus, called a provirus,
a rather frequent complaint is able to produce new viral parti-
in general practice. Patients cles. A characteristic of HTLV-1 is
will often express some mi- that the virus increases by the clonal
nor discomfort either during expansion of infected cells, thus the
chewing or maximum open- proliferation of T-cells with reduced
ing that transpired and re- infection-fighting ability.
solved. In most cases, there
will be little more than cur- Case Report
sory palpation of the joint, an The patient was a 32-year-old white
observation of the envelope female who presented for a routine
of motion, and a review of oral hygiene visit. She had excellent
the history. The patient may oral hygiene, no restorations, no
report nothing else of inter- active caries, no appreciable peri-
est and there will be no oth- odontal pocketing, class I orthodon-
er findings. If the symptoms tic position, and no signs of brux-
have resolved there may be ism. During the visit she reported
little to nothing done other Figure 1. The development of blood cells from a stem cell. 4 some TMJ pain first on one side
than the offer to return if the then it stopped, and after some peri-
symptoms persist. Eventually, od of time, it appeared on the other
some patients may report a history of joint infection as well as normal white blood cells side. This was about one month before the
pain elsewhere over a period of time which and the proliferation can crowd out normal appointment and the patient was unsure of
could connect to a pattern of joint inflam- cells. The result is a propensity for infec- the timing. She reported that it would, “Hurt
mation. This may be actionable and lead to tion, anemia, and easy bleeding. Each year when I eat.” When she reported this to her
some more testing and a referral or diagno- some 6000 new cases of ALL are diagnosed friends and family they advised her that it
sis in the US. The highest risk is children under may be ‘TMJ’. Coincidently, the patient re-
five years, and boys and men are slightly at cently had her first COVID 19 vaccination
In this case report, the patient reported higher risk than girls and women. and wondered if the vaccine was the cause
vague symptoms which could not be asso- of her symptoms.
ciated with a dental problem. The patient ALL symptoms include: 2
also had recently received the first of two By the the time she arrived for her dental
COVID vaccinations and was not sure if • Weakness visit, the symptoms had resolved. During
her symptoms were associated with the • Fatigue this appointment her range of motion was
vaccination. When the symptoms persist- • Fever normal, there were no sounds from the joints
ed, she sought medical care and a routine • Night sweats and each TMJ appeared to operate normally.
CBC detected an elevated white blood cell • Shortness of breath A head and neck exam did not reveal any-
count. With subsequent testing, a diagnosis • Unusual or easy bleeding or bruising thing unusual. The patient volunteered that
of adult T-cell leukemia (ATL) was made. • Unexplained loss of appetite or she had been under some moderate stress
weight loss and opined if that could be the cause. The
It is estimated that approximately 15% of • Bone or stomach pain patient was told to return for further evalua-
human cancers are attributed to some viral • Frequent infections tion if the symptoms returned.
infection. Viral genomes have been de- • Tiny, dark red spots under the skin
1
tected in host cellular DNA for a number of • A feeling of pain or fullness below Approximately ten days later the patient
diseases, including cervical cancer- human the ribs was at a zoo and noticed a swelling in her

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