Updated: 6/17/2021

Pseudogout (CPPD)

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  • summary
    • Pseudogout is a common form of inflammatory arthritis caused by intra-articular calcium pyrophosphate dihydrate crystal deposition and presents with attacks of joint pain, joint stiffness and swelling.
    • Diagnosis is made by joint aspiration and crystal analysis showing weakly positively birefringent rhomboid-shaped crystals
    • Treatment is usually medical management with NSAIDs.
  • Epidemiology
    • Demographics
      • commonly affects the elderly
      • rarely affects younger patients, unless occurring in conjunction with other disease
  • Etiology
    • Associated conditions
      • hemochromatosis
      • hyperparathyroidism
      • SLE
      • gout
      • RA
      • Wilson's disease
      • hemophilia
      • long term hemodialysis can cause a pyrophosphate like deposition disorder
      • chondrocalcinosis is present in 7% of patients
    • Mimics gout except
      • affects older patients > 60 years old
      • affects more proximal joints
      • positively-birefringent crystal
  • Presentation
    • Symptoms
      • acute, onset joint tenderness
      • warm, erythematous joint
      • commonly on knee and wrist joints
    • Physical exam
      • erythematous, monoarticular arthritis
      • joints tender to palpation
      • may observe superficial mineral deposits under the skin at affected joints
  • Imaging
    • Radiographs
      • may see calcification of fibrocartilage structures (chondrocalcinosis)
        • TFCC in wrist
  • Evaluation
    • Joint aspiration crystal analysis
      • weakly positively birefringent rhomboid-shaped crystals
  • Treatment
    • Acute pseudogout
      • nonoperative
        • NSAIDS
        • splint
        • intra-articular steroids
        • splints for comfort
    • Chronic pseudogout
      • nonoperative
        • intraarticular yttrium-90 injections
        • colchicine ( 0.6 mg PO bid for recurrent cases)
          • prophylactic colchine can help to prevent recurrence
  • Complications
    • Can result in permanent damage to the joints and renal disease

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Questions (2)
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(SBQ07SM.13) A 53-year-old male laborer presents to his primary care physician with complaints of acute onset of left knee pain. He has had mild episodes of knee pain in the past and is two years status post a left partial medial meniscectomy. He has had mild relief with the use of anti-inflammatories. His past medical history is significant only for hyperparathyroidism and mild hypertension. He denies any fevers or chills. His exam reveals a moderate knee effusion and diffuse pain and tenderness with palpation and range of motion. Weightbearing radiographs are shown below. The most likely etiology of the patient's knee pain is characterized by which finding?

QID: 1398
FIGURES:
1

Deposits of monosodium urate crystals

6%

(118/2140)

2

Deposits of calcium pyrophosphate-dihydrate crystals

89%

(1897/2140)

3

Destructive pannus formation

2%

(40/2140)

4

Empty osteocyte lacunae

2%

(50/2140)

5

Recurrent hemarthroses

1%

(20/2140)

L 1 C

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