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. [1,2] 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. [1,3]
Restricted movements of the joint Due to severe pain [1]
Joint swelling Due to the inflammation triggered by calcium pyrophosphate crystal deposition in joints. [1,3]
Redness over the joint Due to the inflammation triggered by calcium pyrophosphate crystal deposition in joints. [1]
Risk factors Old age ,advanced osteoarthritis and neuropathic joints are risk factors.[1,3,4]
Associations Acute attacks of pseudogout have been reported following gouty arthritis, diuretic therapy, cerebrovascular accidents, myocardial infarction or bacterial infections. [5] Studies have shown a strong association of hyperparathyroidism, hypothyroidism, diabetes and haemochromatosis with pseudogout.[1,3,4,6]
References
  1. MACMULLAN P, MCCARTHY G. Treatment and management of pseudogout: insights for the clinician Ther Adv Musculoskelet Dis [online] 2012 Apr, 4(2):121-131 [viewed 15 May 2014] Available from: doi:10.1177/1759720X11432559
  2. WRIGHT GD, DOHERTY M. Calcium pyrophosphate crystal deposition is not always 'wear and tear' or aging. Ann Rheum Dis [online] 1997 Oct, 56(10):586-8 [viewed 15 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9389218
  3. DIEPPE P. New knowledge of chondrocalcinosis J Clin Pathol Suppl (R Coll Pathol) [online] 1978:214-222 [viewed 15 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1347141
  4. ELBORN JS, KELLY J, ROBERTS SD. Pseudogout, chondrocalcinosis and the early recognition of haemochromatosis. Ulster Med J [online] 1992 Apr, 61(1):119-123 [viewed 15 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2448774
  5. TILL G, MIOR SA. Calcium pyrophosphate dihydrate crystal deposition disease: A report of a case J Can Chiropr Assoc [online] 1988 Mar, 32(1):23-27 [viewed 15 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2484460
  6. PRITCHARD M H, JESSOP J D. Chondrocalcinosis in primary hyperparathyroidism. Influence of age, metabolic bone disease, and parathyroidectomy.. Annals of the Rheumatic Diseases [online] 1977 April, 36(2):146-151 [viewed 15 May 2014] Available from: doi:10.1136/ard.36.2.146

Examination

Fact Explanation
Joint tenderness Due to the inflammation triggered by the Calcium Pyrophosphate crystal deposition in joints. [1,2]
Redness over the joint Vasodilatation due to the inflammatory reaction causes erythema over the affected joints namely knee, wrist, shoulders, ankles or elbows. [1,2]
Desquamation Occasional desquamation of skin overlying the affected joint is present. This is more common in gout. [1]
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. [3]
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. [4]
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. [5]
References
  1. MACMULLAN P, MCCARTHY G. Treatment and management of pseudogout: insights for the clinician Ther Adv Musculoskelet Dis [online] 2012 Apr, 4(2):121-131 [viewed 15 May 2014] Available from: doi:10.1177/1759720X11432559
  2. TILL G, MIOR SA. Calcium pyrophosphate dihydrate crystal deposition disease: A report of a case J Can Chiropr Assoc [online] 1988 Mar, 32(1):23-27 [viewed 15 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2484460
  3. ALLAGUI M, MAGHREBI S, TOUATI B, KOUBAA M, HADHRI R, HAMDI MF, ABID A. Posterior interosseous nerve syndrome due to intramuscular lipoma Eur Orthop Traumatol [online] 2014:75-79 [viewed 16 May 2014] Available from: doi:10.1007/s12570-013-0203-5
  4. MCCARTY DJ. Milwaukee shoulder syndrome. Trans Am Clin Climatol Assoc [online] 1991:271-284 [viewed 16 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2376669
  5. O'HARA LAWRENCE J.. Carpal Tunnel Syndrome and Gout. Arch Intern Med [online] 1967 August [viewed 16 May 2014] Available from: doi:10.1001/archinte.1967.00300020052006

Differential Diagnoses

Fact Explanation
Septic arthritis Septic arthritis has a classical triad of symptoms, namely low grade fever, pain and impaired range of motion. It presents as a mono arthritis. The symptoms may evolve over a few days to weeks. [1]
Gout Gout is characterized by recurrent attacks of acute inflammatory arthritis. Gout has become more common in recent decades. It affects more commonly in men aged 20 -40 years and in women older than 50 years. Abrupt onset of severe excruciating joint pain most commonly affects the metatarsal-phalangeal joint of the great toe is the classical feature of acute gouty arthritis. The big toe is not the only joint that can be affected by gout symptoms. Pain can appear in many joints, including fingers, wrists, elbows, knees, ankles and feet. Acute attack of gout usually affect one joint. [2]
Bursitis Bursitis is the inflammation of bursae of synovial fluid in the body. It commonly affects superficial bursae. Symptoms vary from localized warmth and erythema to joint pain and stiffness. [3]
Osteoarthritis Osteoarthritis is a common rheumatologic disorder characterized by abnormalities of articular hyaline cartilage, subchondral bone and other surrounding tissue such as muscles and ligaments. It occurs common in weight-bearing joints such as hip and knee. Spine and hands are also affected sometimes. The prevalence among men and women is equal. However, osteoarthritis occurs earlier in women. Joint pain is usually slow in onset, with gradual and intermittent increase. It can be diffuse/ sharp and stabbing in character which is initially relieved by rest but later on disturbs sleep. Vigorous activity may cause pain to flare up. Distribution is often asymmetric. [4]
Rheumatoid arthritis Chronic symmetrical inflammatory polyarthritis affecting small and large joints including hand, knee, wrist, ankle and neck. Deformity may vary depending on the joint affected in hand. These include ulnar deviation, boutonniere deformity, swan neck deformity and Z-thumb (hyperextension of the interphalangeal joint, fixed flexion and subluxation of the metacarpo-phalangeal joint). There are extra articular manifestations such as subcutaneous nodules and carpal tunnel syndrome. More commonly seen in females. [5]
References
  1. CARPENTER CHRISTOPHER R., SCHUUR JEREMIAH D., EVERETT WORTH W., PINES JESSE M.. Evidence-based Diagnostics: Adult Septic Arthritis. [online] December, 18(8):781-796 [viewed 14 May 2014] Available from: doi:10.1111/j.1553-2712.2011.01121.x
  2. EGGEBEEN,A.T. Gout: An Update. Am Fam Physician[online], 2007,76,801-8, 811-2. [viewed 14 May 2014] Available from: http://www.aafp.org/afp/2007/0915/p801.html
  3. TELL IM. Management of acute bursitis: outcome study of a structured approach. J R Soc Med [online] 1999 Oct, 92(10):516-521 [viewed 14 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1297391
  4. SINUSAS,K. Osteoarthritis: Diagnosis and Treatment, Am Fam Physician[online]. 2012,85(1),49-56. [viewed 2 May 2014]. Available from: http://www.aafp.org/afp/2012/0101/p49.html
  5. RICHIE, A.M, M.L.FRANCIS,Diagnostic Approach to Polyarticular Joint Pain, Am Fam Physician[online]. 2003 Sep, 15,68(6),1151-1160. [viewed 2 May 2014]. Available from: http://www.aafp.org/afp/2003/0915/p1151.html

Investigations - for 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.[1]
Erythrocyte sedimentation rate (ESR) ESR may be elevated due to inflammation. [1]
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. [1,2]
Serum calcium To exclude hyperparathyroidism when the serum level of calcium increases/decreases. [1,2]
Serum phosphate To exclude hyperparathyroidism when the serum level of phosphates increases/decreases. [1,2]
Alkaline phosphatase To exclude hyperparathyroidism when the serum level of alkaline phosphatase increases/decreases. [1,2]
Thyroid-stimulating hormone (TSH) To exclude hypothyroidism when the serum level of TSH increases. [1,2]
Serum ferritin To exclude haemochromatosis when the serum level of serum ferritin increases. [1,2]
Iron saturation To exclude haemochromatosis when the iron saturation increases. [1,2]
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. [1,2,3]
References
  1. MACMULLAN P, MCCARTHY G. Treatment and management of pseudogout: insights for the clinician Ther Adv Musculoskelet Dis [online] 2012 Apr, 4(2):121-131 [viewed 15 May 2014] Available from: doi:10.1177/1759720X11432559
  2. TILL G, MIOR SA. Calcium pyrophosphate dihydrate crystal deposition disease: A report of a case J Can Chiropr Assoc [online] 1988 Mar, 32(1):23-27 [viewed 15 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2484460
  3. FAM AG, TOPP JR, STEIN HB, LITTLE AH. Clinical and roentgenographic aspects of pseudogout: a study of 50 cases and a review. Can Med Assoc J [online] 1981 Mar 1, 124(5):545-551 [viewed 15 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1705201

Management - General Measures

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. [1,2]
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. [1,2]
Colchicine Oral colchicine or intravenous colchicine, can be considered as the last resort of pain relief for the treatment of acute pseudo gout. [1,2]
Synovial fluid aspiration Sometimes helps in relieving pain by removing inflammatory mediators from joint cavity. [1,2]
References
  1. MACMULLAN P, MCCARTHY G. Treatment and management of pseudogout: insights for the clinician Ther Adv Musculoskelet Dis [online] 2012 Apr, 4(2):121-131 [viewed 15 May 2014] Available from: doi:10.1177/1759720X11432559
  2. DIEPPE P. New knowledge of chondrocalcinosis J Clin Pathol Suppl (R Coll Pathol) [online] 1978:214-222 [viewed 15 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1347141

Management - Specific Treatments

Fact Explanation
Anticrystal therapy (eg- Probenecid, Phosphocitrate) Still lacks evidence,but may play a role in future management. [1]
Methotrexate Stronger anti inflammatory drug that can help some patients during severe attacks. [1]
Surgery Sometimes performed to repair or replace any damaged joints. [1]
References
  1. MACMULLAN P, MCCARTHY G. Treatment and management of pseudogout: insights for the clinician Ther Adv Musculoskelet Dis [online] 2012 Apr, 4(2):121-131 [viewed 15 May 2014] Available from: doi:10.1177/1759720X11432559