Crystal Arthropathies Including Gout

Content

• Prevention Of Recurrent Attacks
• Joint Aspiration
• The Rheumatologist's Role In The Treatment Of Cppd
• Clinical Manifestations
• What Are Pseudogout Symptoms And Signs?
• Features Of Cppd:

Pseudogout occurs when calcium pyrophosphate crystals form in the synovial fluid in the joints. Crystals can also deposit in the cartilage, where they can cause damage. Buildup of crystal in the joint fluid results in swollen joints and acute pain.

This video describes the pathophysiology, causes, symptoms, and treatment of gout. Gout and pseudogout are the two most common crystal-induced arthropathies. Gout is caused by monosodium urate monohydrate crystals; pseudogout is caused by calcium pyrophosphate crystals and is more accurately termed calcium pyrophosphate disease . (See Pathophysiology and Etiology.) Gout is one of the oldest diseases in the medical literature, known since the time of the ancient Greeks. Pseudogout, which may be clinically indistinguishable from gout, was recognized as a distinct disease entity in 1962. Sudden painful attacks are usually less severe than those of gout, but, as in gout, attacks in calcium pyrophosphate arthritis can cause fever.

Prevention Of Recurrent Attacks

In addition to medications, splints or compressive wraps may be helpful to decrease swelling and lessen pain. Gout may cause crystals to form white nodules called “tophi” that are often visible under the skin . If the skin is too swollen and stretched out, a white chalky substance may ooze from the joint. The elbow, wrist, and small finger joints are common sites for gout. A subset of patients may present with spinal involvement, occasionally causing clinical manifestations such as spine stiffness and bony ankylosis resembling ankylosing spondylitis.

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In addition to the great toe, other areas affected include the insteps, heels, ankles, knees, fingers, wrists and elbows. The best studied but still not widely used technique for crystal identification is alizarin red S staining for apatites and other calcium containing crystals. This procedure described by Paul et al stains apatite containing clumps as bright red, round, occasionally Chinese coin-like or irregular 3 – 15 μ bodies (Fig. 4). CPPD and oxalate (Fig. 5) will also stain red but retain their typical shapes and stain more slowly. Urate crystals have been stained with De Golantha silver stain or methylene blue but any clinical value of these has not been tested.

Calcium pyrophosphate deposition disease , commonly called pseudogout due to the symptomatic similarity to gout, is one of the many forms of arthritis. Both conditions result from crystal deposits within a joint, although the type of crystal differs. Gout results from deposition of urate crystals while CPPD results from deposition of calcium pyrophosphate crystals. Calcium pyrophosphate deposition disease is a crystal deposition disease in the joints and soft tissue, resulting in inflammation and tissue damage. The clinical presentation resembles gout in its acute attacks of crystal synovitis and, thus, was previously called pseudogout.

Joint Aspiration

Pérez Ruiz F, Alonso Ruiz A, Calabozo M, García Erauskin G, Herero Beites A, Duruelo J. Reduced clearance of urate is present even in patients with overexcretion of urate. 35], which does not result in hyperuricaemia, may be an alternative. A lack of response to hypouricaemic treatment is unusual, and generally due to poor compliance; maintenance of heavy alcohol consumption may also result in a poor response to the drugs.

Its anti-inflammatory role was evident in a study performed on five patients. Their acute CPPD was resistant to classic treatment with NSAIDs and steroids. Low-dose MTX (5-20 mg/week) significantly reduced the amount of pain, swelling of joints and the serum levels of inflammatory biomarkers . Another observational study performed on 10 patients showed MTX being beneficial for treating acute inflammation in patients with treatment-resistant CPPD by conventional therapies .

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If the disease has eroded the joints or if tendons have been compromised, surgery may be indicated to remove the crystals and stabilize the joint. Diagnostic confirmation may be via the presence of rhomboid crystals in the synovial fluid aspirate visualized under polarized microscopy. These are just 12 of the many nutritious foods that can help ease pain and discomfort brought about by arthritis and joint pains. If your diet consists of joint pain triggering food like crabs, oysters, sweetbreads, and other high-sugar content foods, replace them with some of these 12 arthritis-fighting foods. Interventional pain management for arthritis is the holistic and advanced approach in relieving pain and discomfort of inflamed joints.

The Rheumatologist's Role In The Treatment Of Cppd

However, diuretics can hamper the kidneys' ability to remove uric acid, thus raising uric acid levels in the blood. Gout is a dramatic example of a type of arthritis called crystal arthritis, sometimes called microcrystalline arthritis because the crystals are very small. As the body tries to remove the crystals, a painful inflammation occurs. In a few patients, surgery may be used to reduce pain and improve movement in a joint that is badly damaged or unstable. Some joints can be partially repaired by removing CPPD crystals or cartilage fragments through an arthroscope . Some joints, especially the hip or knee, can be replaced with an artificial joint made of plastic and metal.

How do you reduce calcification in your body?

There is no proven way to prevent calcifications, as they're a result of a variety of biological processes. Quitting smoking and changing diet may impact formation of calcifications, depending on the location of the buildup. Kidney stones may form less often with certain dietary changes.

Whether these patients represent CPPD arthropathy superimposed on rheumatoid arthritis or whether this is CPPD alone presenting as pseudorheumatoid arthritis remains to be determined. In chronic CPP inflammatory arthritis, mild anemia with a modest elevation in acute-phase reactants is not uncommon. The frequency of other biochemical and serologic abnormalities, however, is no different from that in other subjects of the same age. A metabolite of pyrazinamide, pyrazinoic acid, inhibits the renal tubular secretion of uric acid and ethambutol also reduces its renal clearance.

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Cartilage cells naturally produce a substance called pyrophosphate. For reasons that are incompletely understood, pyrophosphate levels may increase in cartilage, leading to the formation of CPPD crystals. Diet and alcohol intake can affect serum uric acid levels as well. For example, meat and seafood are rich in purines, and overconsumption of these foods is associated with gout. Surgical treatment is occasionally performed to relieve the symptoms of a painful flare by cleaning out the joint crystals and calcification. Tinahones FJ, Collantes E, C-Soriguer FJ, González Ruiz A, Pineda M, Añón J et al.

If the tophi are not prevented or treated, they can damage joints . Walking, bicycling and aquatic exercises are often recommended for people with CPPD crystal deposition disease. During times when CPPD crystal deposition disease is not active, strengthening exercises can be done to ensure maximum function and stability of your joints. These exercises should be taught by a physical or occupational therapist or physician, preferably one who is familiar with CPPD crystal deposition disease.

The chief complaint associated with an acute attack of gout is agonizing pain accompanied by signs of inflammation, including swelling, erythema, warmth and tenderness. A low-grade fever may occur in conjunction with the inflammation. Acute attacks usually peak within one to two days of symptom onset. Any abrupt change in the serum uric acid concentration may provoke an acute attack of gouty arthritis. Electron microscopy can identify very small crystals by morphology (Fig. 8) and can allow confirmation by electron diffraction elemental analysis (Fig. 9). X-ray diffraction or Fourier transform infra red analysis are the most definitive methods for crystal identification but require more crystals than are often available.

Additionally, it could potentially decrease the need for using more expensive imaging modalities such as MRI. Other measures include the application of ice packs and joint rest with restriction of weight-bearing to decrease further inflammation. Patients with recurrent episodes of acute CPP arthritis may receive daily low-dose colchicine. Deposition of calcium pyrophosphate is believed to cause activation of the immune system producing inflammation and further soft tissue injury.

Features Of Cppd:

These criteria take advantage of the features of gout that separate it from other types of inflammatory arthritis, such as rheumatoid arthritis. For example, the inflammation of gout tends to reach a maximum within 24 hours, while other types of arthritis tend to evolve more slowly. Likewise, the presence of redness over a joint, the involvement of the “bunion” joint, and a high blood level of uric acid are all features making gout more likely. The diagnosis of gout is made in the presence of 6 of the 10 criteria listed in Table 1. A healthy 70-year-old woman presented with a 10-year history of right temporomandibular joint pain and an ear lump. She was referred for acute worsening, new onset of left TMJ pain, and right-sided hearing loss.