Pseudogout - Clinicals, Diagnosis, and Management

Rheumatology

Clinicals - History

Fact Explanation
Joint pain Pseudogout is an acute inflammatory monoarticular or oligoarticular arthritis. It is more common in elderly women. Calcium pyrophosphate deposits in hyaline and fibrocartilage (chondrocalcinosis) can ultimately shed crystals into a joint which trigger acute synovitis. Pyrophosphate is a by-product of multiple intracellular biosynthetic reactions.
Abrupt onset of severe joint pain usually involves knee and wrist. Shoulders, ankles and elbows are the other joints affected.
These attacks may occur spontaneously or can be provoked by trauma, surgery or severe medical illness.
Joint pain
Pseudogout is an acute inflammatory monoarticular or oligoarticular arthritis. It is more common in elderly women. Calcium pyrophosphate deposits in hyaline and fibrocartilage (chondrocalcinosis) can ultimately shed crystals into a joint which trigger acute synovitis. Pyrophosphate is a by-product of multiple intracellular biosynthetic reactions.
Abrupt onset of severe joint pain usually involves knee and wrist. Shoulders, ankles and elbows are the other joints affected.
These attacks may occur spontaneously or can be provoked by trauma, surgery or severe medical illness.
Restricted movements of the joint Due to severe pain Restricted movements of the joint
Due to severe pain
Joint swelling Due to the inflammation triggered by calcium pyrophosphate crystal deposition in joints. Joint swelling
Due to the inflammation triggered by calcium pyrophosphate crystal deposition in joints.
Redness over the joint Due to the inflammation triggered by calcium pyrophosphate crystal deposition in joints. Redness over the joint
Due to the inflammation triggered by calcium pyrophosphate crystal deposition in joints.
Risk factors Old age ,advanced osteoarthritis and neuropathic joints are risk factors. Risk factors
Old age ,advanced osteoarthritis and neuropathic joints are risk factors.
Associations Acute attacks of pseudogout have been reported following gouty arthritis, diuretic therapy, cerebrovascular accidents, myocardial infarction or bacterial infections.
Studies have shown a strong association of hyperparathyroidism, hypothyroidism, diabetes and haemochromatosis with pseudogout.
Associations
Acute attacks of pseudogout have been reported following gouty arthritis, diuretic therapy, cerebrovascular accidents, myocardial infarction or bacterial infections.
Studies have shown a strong association of hyperparathyroidism, hypothyroidism, diabetes and haemochromatosis with pseudogout.

Clinicals - Examination

Fact Explanation
Joint tenderness Due to the inflammation triggered by the Calcium Pyrophosphate crystal deposition in joints. Joint tenderness
Due to the inflammation triggered by the Calcium Pyrophosphate crystal deposition in joints.
Redness over the joint Vasodilatation due to the inflammatory reaction causes erythema over the affected joints namely knee, wrist, shoulders, ankles or elbows. Redness over the joint
Vasodilatation due to the inflammatory reaction causes erythema over the affected joints namely knee, wrist, shoulders, ankles or elbows.
Desquamation Occasional desquamation of skin overlying the affected joint is present. This is more common in gout. Desquamation
Occasional desquamation of skin overlying the affected joint is present. This is more common in gout.
Decrease in the extension strength of the wrist and metacarpophalangeal joints of the fingers and thumb. Pseudogout at the elbow joint causes joint swelling which compresses the Posterior interosseous branch of the radial nerve at the elbow level.It decreases the extension strength of the wrist and metacarpo-phalangeal joints of the fingers and thumb with no sensory deficit. Decrease in the extension strength of the wrist and metacarpophalangeal joints of the fingers and thumb.
Pseudogout at the elbow joint causes joint swelling which compresses the Posterior interosseous branch of the radial nerve at the elbow level.It decreases the extension strength of the wrist and metacarpo-phalangeal joints of the fingers and thumb with no sensory deficit.
Limited active range of motion of shoulder Milwaukee shoulder syndrome is an associated condition of pseudo gout. Peri or intra articular deposition of crystals
precipitates acute changes in joint structure and function. Subsequently rotator cuff is also affected resulting limitations in active movements of shoulder joint.
Limited active range of motion of shoulder
Milwaukee shoulder syndrome is an associated condition of pseudo gout. Peri or intra articular deposition of crystals
precipitates acute changes in joint structure and function. Subsequently rotator cuff is also affected resulting limitations in active movements of shoulder joint.
Carpal tunnel syndrome Entrapment of the median nerve secondary to intratendinous infiltration by gouty tophi is a rare cause of developing carpal tunnel syndrome manifested as motor and sensory abnormalities distal to the wrist. Carpal tunnel syndrome
Entrapment of the median nerve secondary to intratendinous infiltration by gouty tophi is a rare cause of developing carpal tunnel syndrome manifested as motor and sensory abnormalities distal to the wrist.

Investigations - Diagnosis

Fact Explanation
White blood cell count Even in the absence of an infection, white blood cell count can be high. This elevation makes it difficult to distinguish from acute septic arthritis. White blood cell count
Even in the absence of an infection, white blood cell count can be high. This elevation makes it difficult to distinguish from acute septic arthritis.
Erythrocyte sedimentation rate (ESR) ESR may be elevated due to inflammation. Erythrocyte sedimentation rate (ESR)
ESR may be elevated due to inflammation.
Synovial Fluid Analysis Examination of synovial fluid is a more accurate method for diagnosing gout. The aspirated sample is examined through a microscope under polarized light. This reveals the presence of rhomboid-shaped crystals with weakly positive birefringence. Joint fluid should be sent for culture to exclude septic arthritis. Synovial Fluid Analysis
Examination of synovial fluid is a more accurate method for diagnosing gout. The aspirated sample is examined through a microscope under polarized light. This reveals the presence of rhomboid-shaped crystals with weakly positive birefringence. Joint fluid should be sent for culture to exclude septic arthritis.
Serum calcium To exclude hyperparathyroidism when the serum level of calcium increases/decreases. Serum calcium
To exclude hyperparathyroidism when the serum level of calcium increases/decreases.
Serum phosphate To exclude hyperparathyroidism when the serum level of phosphates increases/decreases. Serum phosphate
To exclude hyperparathyroidism when the serum level of phosphates increases/decreases.
Alkaline phosphatase To exclude hyperparathyroidism when the serum level of alkaline phosphatase increases/decreases. Alkaline phosphatase
To exclude hyperparathyroidism when the serum level of alkaline phosphatase increases/decreases.
Thyroid-stimulating hormone (TSH) To exclude hypothyroidism when the serum level of TSH increases. Thyroid-stimulating hormone (TSH)
To exclude hypothyroidism when the serum level of TSH increases.
Serum ferritin To exclude haemochromatosis when the serum level of serum ferritin increases. Serum ferritin
To exclude haemochromatosis when the serum level of serum ferritin increases.
Iron saturation To exclude haemochromatosis when the iron saturation increases. Iron saturation
To exclude haemochromatosis when the iron saturation increases.
Radiography Non weight-bearing anteroposterior (AP) view of both knees, an AP view of the pelvis for visualization of the symphysis pubis and hips, and a posteroanterior (PA) view of each hand to include the triangular ligament of the wrists are usually taken. Changes in the metacarpophalangeal joints, such as squaring of the bone
ends, presence of subchondral cysts and hooklike osteophytes, are found in pseudogout.
Radiography
Non weight-bearing anteroposterior (AP) view of both knees, an AP view of the pelvis for visualization of the symphysis pubis and hips, and a posteroanterior (PA) view of each hand to include the triangular ligament of the wrists are usually taken. Changes in the metacarpophalangeal joints, such as squaring of the bone
ends, presence of subchondral cysts and hooklike osteophytes, are found in pseudogout.

Management - Supportive

Fact Explanation
Non Steroidal Anti-Inflammatory Drugs (NSAIDs) NSAIDs can be used to relieve pain in patients with acute pseudo gout. NSAIDs have many adverse effects such as gastrointestinal ulcer disease, bleeding or perforation. These are increased in the elderly and a proton pump inhibitor should be co administered. These should be used cautiously in renal insufficiency. NSAIDs may be relatively contraindicated in the older population. Non Steroidal Anti-Inflammatory Drugs (NSAIDs)
NSAIDs can be used to relieve pain in patients with acute pseudo gout. NSAIDs have many adverse effects such as gastrointestinal ulcer disease, bleeding or perforation. These are increased in the elderly and a proton pump inhibitor should be co administered. These should be used cautiously in renal insufficiency. NSAIDs may be relatively contraindicated in the older population.
Corticosteroids Excellent symptomatic relief with intra-articular injections. Some evidence for short courses of oral/intramuscular steroids for
poly articular flares. Septic arthritis should be excluded prior commencing steroids.
Corticosteroids
Excellent symptomatic relief with intra-articular injections. Some evidence for short courses of oral/intramuscular steroids for
poly articular flares. Septic arthritis should be excluded prior commencing steroids.
Colchicine Oral colchicine or intravenous colchicine, can be considered as the last resort of pain relief for the treatment of acute pseudo gout. Colchicine
Oral colchicine or intravenous colchicine, can be considered as the last resort of pain relief for the treatment of acute pseudo gout.
Synovial fluid aspiration Sometimes helps in relieving pain by removing inflammatory mediators from joint cavity. Synovial fluid aspiration
Sometimes helps in relieving pain by removing inflammatory mediators from joint cavity.

Management - Specific

Fact Explanation
Anticrystal therapy (eg- Probenecid, Phosphocitrate) Still lacks evidence,but may play a role in future management. Anticrystal therapy (eg- Probenecid, Phosphocitrate)
Still lacks evidence,but may play a role in future management.
Methotrexate Stronger anti inflammatory drug that can help some patients during severe attacks. Methotrexate
Stronger anti inflammatory drug that can help some patients during severe attacks.
Surgery Sometimes performed to repair or replace any damaged joints. Surgery
Sometimes performed to repair or replace any damaged joints.

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