This document summarizes a noon conference presentation on pseudogout (calcium pyrophosphate crystal deposition disease). The presentation discusses the clinical presentation of pseudogout including acute attacks characterized by intense pain and swelling typically in the knees. Diagnosis involves identification of positively birefringent calcium pyrophosphate crystals in synovial fluid or tissue. Treatment depends on the number of affected joints, ranging from joint aspiration and steroid injection for one or two joints to NSAIDs and colchicine for more extensive involvement. The presentation also provides an illness script comparing pseudogout to gout and reviews associated conditions requiring further evaluation.

1. Noon Conference
Miao Yu, MS-3
09/11/2018

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Objectives
Pseudogout - Calcium Pyrophosphate
Crystal Deposition (CPPD) disease
• Discuss clinical presentation
• Review diagnostic test
• Review diagnostic criteria
• Review illness script
• Discuss treatment

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Clinical presentation
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Range from asymptomatic CPPD disease to acute CPP crystal arthritis
Acute CPP crystal arthritis:
• ‘pseudogout’
• Intense pain, redness, warmth, swelling and
joint disability
• >50% in knee, other joints: MCPs, shoulder,
ankles, and elbows
• An upper extremity site for 1st attack → raise
suspicion for pseudogout
• Trauma, surgery or severe medical illness provoke
acute attacks

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Question
Which of the following is a description of
calcium pyrophosphate crystals?
a.negatively birefringent material
b.positively birefringent material
c. colorless bipyramids of various sizes
d.needle like granular yellow crystals
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Diagnostic criteria
Definite :
• Presence of both positively birefringent crystals by
polarized light microscopy and typical cartilage calcification
on radiograph
OR
CPP crystals in tissue or synovial fluids by definitive means
(e.g X-ray diffraction, Fourier transform infrared spectroscopy)
In practice:
Positively birefringent crystals
OR
Cartilage calcification on radiograph
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Calcium pyrophosphate crystals
vv
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positive birefringent rhomboid crystals
Variation in shape and sizes….
Some of the particles do not
display birefringence….

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right lung nodules and infiltrates

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Radiology
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https://www.orthobullets.com/

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Post-diagnostic evaluation for
associated diseases
• Hypomagnesemia
• Mg
• Hemochromatosis
• Ferritin, iron and transferrin
• Hyperparathyroidism
• Calcium
• Phosphorus
• Alkaline phosphatase
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Treatment
Initial treatment for 1 or 2 joints:
• Joint aspiration
• Intraarticular glucocorticoid injection
Initial treatment for more than 2 joints:
• NSAIDs, colchicine, glucocorticoids
Prophylaxis for acute pseudogout:
• Colchicine 0.6 mg twice daily
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Illness Scripts
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Pseudogout Gout
Pathophysiology Calcium pyrophosphate crystal deposition
Crystallization of uric acid within joints
Uric acid overproduction vs. underexcretion
Epidemiology
Older ( <50 is rare), female
Associations: prior joint surgery/, trauma,
amyloidosis, hypomagnesemia,
hyperparathyroidism
Younger, male
Associations: DM, HTN, metabolic syndrome,
obesity, renal stones, CPPD
Time course Asymptomatic, acute, subacute, chronic
asymptomatic, acute intermittent arthritis, chronic
arthritis with acute exacerbations
Clinical
presentation/Loc
ation
knee, wrist, ankle big toe, ankle, knee, hand
Diagnostics
Labs: leukocytosis, increased ESR, usually nl
RF, ANA.
Synovial fluid: positively birefringent
rhomboid shape crystals, more difficult to
detect
Radiology: Calcification densities in hyaline or
fibrocartilage-chondrocalcinosis
Labs: hyperuricemia ( hallmark of gout, but not
by itself diagnostic), leukocytosis, increased
ESR
Synovial Fluid: negatively birefringent
crystals, leukocyte counts=septic arthritis.
Viscosity < septic or inflammatory arthritis
Radiology: overhanging edges, pouched out
lesions with sclerotic borders
Therapeutics
Acute: Joint aspiration, intraarticular steroids,
NSAIDS, Colchicine, Corticosteroids
Dietary modification not helpful
Acute: Corticosteroids, NSAIDS, Colchicine
Allopurinol, Dietary modification

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Gout or Pseudogout?
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Terry Shaneyfelt, MD, MPH

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Acknowledgements
TEAM Best!
Dr. Jackie Lemon
Dr. Evan Yount
Dr. Jessica Rakonza
Dr. Di Yan
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