Pseudogout - Treatment and Diagnosis | GetWellGo

Pseudogout Treatment

Treatment of Pseudogout:

Acute Attack Treatment

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

• e.g., naproxen, ibuprofen, indomethacin
• For pain and inflammation (avoid in patients with kidney disease or peptic ulcer)

Colchicine

• Best if initiated early in an attack
• Can cause gastrointestinal side effects

Corticosteroids

• Oral: prednisone (short course)
• Intra-articular injection: triamcinolone into the involved joint
• Helpful when NSAIDs or colchicine are contraindicated

Joint Aspiration (Arthrocentesis)

• Draining joint fluid relieves pressure and pain
• Fluid analysis also establishes diagnosis by identifying CPPD crystals

Chronic/Preventive Management

• Low-dose colchicine for multiple attacks
• Lifestyle changes
• Hydrate
• Prevent joint trauma
• Manage underlying conditions such as hyperparathyroidism, hemochromatosis, or hypomagnesemia

Manage underlying metabolic disorders:

• Restore calcium, magnesium, or phosphate balance

Supportive Measures

• Rest the involved joint during flare-ups
• Cold compresses to decrease inflammation and pain

Pseudogout Diagnosis

Diagnosis of pseudogout combines clinical assessment, imaging, and joint fluid analysis.

Clinical History and Symptoms

• Abrupt onset of joint pain, swelling, redness, and heat

Most frequently involves:

• Knees, wrists, shoulders, ankles, and elbows
• Can present similarly to gout, septic arthritis, or osteoarthritis flare

Joint Aspiration and Synovial Fluid Analysis (Gold Standard)

• Synovial fluid aspiration from the affected joint is the most important test.

Fluid is analyzed for:

• Calcium pyrophosphate crystals: rhomboid-appearing, positively birefringent under polarized light microscopy (in contrast to gout, which features negatively birefringent urate crystals)
• Cell count and culture to exclude infection

Imaging Tests

X-rays: may reveal:

• Chondrocalcinosis (calcification of joint cartilage)
• Narrowing or degenerative change of joint space
• Ultrasound or CT: more sensitive for detecting calcifications
• MRI: helpful if suspicion of other joint pathology is raised

Blood Tests

• Help to exclude other reasons for joint pain

May involve:

• Serum uric acid (to distinguish from gout)
• Calcium, magnesium, phosphate, iron studies, and parathyroid hormone (PTH) to seek underlying metabolic disorders

Calcium Pyrophosphate Deposition Disease

Calcium Pyrophosphate Deposition Disease (CPPD) — also referred to as pseudogout — is a form of crystal-induced arthritis due to the deposition of calcium pyrophosphate dihydrate (CPP) crystals within the joints and adjacent tissues.

Pseudogout Symptoms

Pseudogout results in acute joint inflammation from calcium pyrophosphate crystal deposits. Symptoms can mimic gout or septic arthritis, but the etiology and involved joints tend to be different.

• Sudden joint pain
• Swelling
• Redness and warmth
• Stiffness
• Tenderness
• Fever
• Multiple attacks

Pseudogout Causes

Pseudogout results from deposition of CPP crystals in the fluid and joint cartilage, and these induce inflammation and give rise to pain and swelling of the joint.

• Age-related: Risk is much greater after age 60 due to degeneration of cartilage
• Genetic/Hereditary: Familial types of CPPD occur (rare) and can result in early onset
• Joint trauma or surgery: Previous injury or joint surgery (e.g., knee replacement) can induce crystal formation
• Metabolic disorders: Several metabolic diseases predispose to CPPD crystal deposition:

1. Hyperparathyroidism
2. Hemochromatosis (iron overload)
3. Hypomagnesemia
4. Hypophosphatasia
5. Hypothyroidism
6. Wilson's disease: Dehydration or illness, Can lead to acute precipitation, particularly in the hospital setting.

Pseudogout vs Gout

Pseudogout

• Pseudogout is due to deposition of calcium pyrophosphate dihydrate (CPP) crystals in the joint spaces. 
• These crystals deposit in cartilage and initiate an inflammatory response, which results in swelling and pain. 
• Crystals of pseudogout are rhomboid in shape and are positively birefringent on polarized light microscopy. 
• Pseudogout tends to affect persons above 60 years, and the incidence is higher as people get older. 
• In pseudogout, the knee is most often involved, followed by the wrist and shoulder. 
• Pseudogout, as well as gout, has sudden, severe pain, but its onset develops over hours to days in pseudogout. 
• The duration of a pseudogout flare is usually from a few days to a few weeks. 
• Pseudogout is usually seen in conditions like hyperparathyroidism, hemochromatosis, hypomagnesemia, and other metabolic abnormalities. 
• In pseudogout, the level of blood uric acid is usually normal because the condition has nothing to do with uric acid. 
• Pseudogout is associated with chondrocalcinosis, which is seen as calcification in the cartilage on X-ray.

Gout

• Gout results from the deposition of monosodium urate (MSU) crystals in the joints as a consequence of elevated blood uric acid levels, usually resulting from underexcretion or overproduction of uric acid. 
• The crystals in gout are needle-shaped and negatively birefringent under polarized light, so the two types of crystals can be differentiated on synovial fluid analysis. 
• Gout typically affects young adults, mostly men between the ages of 30–50, although women may also be affected, particularly after menopause. 
• Gout, however, most often involves the big toe (1st metatarsophalangeal joint) but can affect other joints such as the ankle, knee, and elbow. 
• Gout attacks most often take place during the night or following a particular stimulus such as alcohol or high-purine foods. 
• Attacks of gout typically last for 3 to 10 days with pain resolving sooner if treated in time. 
• Gout is commonly associated with hyperuricemia, renal disease, obesity, hypertension, and metabolic syndrome. 
• Gout is directly correlated with increased uric acid levels, although the level of uric acid may be normal during an attack. 
• Gout, however, might demonstrate joint erosions and "rat-bite" lesions on X-ray at more advanced degrees of the disorder.

Pseudogout Arthritis

Pseudogout arthritis is an arthropathy produced by the deposition of calcium pyrophosphate dihydrate (CPP) crystals in joints. Pseudogout is a crystalline-induced form of arthritis, as in the case of gout, but due to alternative crystals. The other name of pseudogout is calcium pyrophosphate deposition disease (CPPD).

Causes and Mechanism

Pseudogout is a condition in which crystals of calcium pyrophosphate precipitate in the cartilage within the joints. These crystals trigger inflammation when deposited within the joint synovial fluid and tissue, eliciting a painful response. The true etiology behind crystal formation remains somewhat obscure but may be brought on by variables including aging, metabolic disease, and trauma to the joint.

Pseudogout Knee Pain

Pseudogout commonly involves the knee joint, which is painful, swollen, and stiff. The condition is a result of calcium pyrophosphate (CPP) crystal deposition within the joint, resulting in inflammation and symptoms similar to those of other types of arthritis, like gout or septic arthritis.

Pseudogout Joint Inflammation

Pseudogout is an arthritis condition that involves sudden inflammation of the joints due to the deposition of calcium pyrophosphate dihydrate (CPP) crystals within the cartilage of the joint. The condition results in an acute inflammatory reaction, resulting in severe pain, swelling, and stiffness of the involved joint. Though it tends to involve larger joints, it can affect any joint in the body.

Mechanism of Joint Inflammation in Pseudogout

When calcium pyrophosphate crystals deposit in the cartilage and synovial fluid of the joints, they cause irritation of the joint tissues, leading to an inflammatory response. The immune system recognizes the crystals as foreign particles and in response produces inflammatory cytokines. This leads to:

• Inflammation of the joint.
• Discomfort resulting from the irritation and trauma induced by the crystals.
• Redness and heat as blood supply to the region increases to fight the inflammation.

Pseudogout and Chondrocalcinosis

• Chondrocalcinosis as a Radiologic Sign: Chondrocalcinosis is also a frequent radiologic sign in pseudogout, that is, calcium pyrophosphate crystals are laid down in the cartilage of the involved joint. They are visible on an X-ray as calcified particles in the cartilage, particularly in joints such as the knee, wrist, shoulder, and hip.
• Not All Episodes of Chondrocalcinosis Are Symptomatic: Although pseudogout is dominated by acute inflammatory joint disease produced by crystal deposition, chondrocalcinosis itself isn't always symptomatic. Individuals may have chondrocalcinosis (visible on X-ray) without ever having an episode of flare of pseudogout or ever having a symptomatic episode of joint pain or inflammation. When this occurs, the condition would be asymptomatic or silent chondrocalcinosis.
• Pseudogout and Chondrocalcinosis: In individuals with pseudogout, chondrocalcinosis is frequently present in involved joints, but not all with chondrocalcinosis develop pseudogout. The crystals may lie dormant for many years prior to triggering an inflammatory flare in a few individuals, prompted by joint injury, infection, or change in metabolism.