Pseudo gout

PSEUDOGOUT DEFINITION — 

— Pseudogout is a form of arthritis that causes sudden attacks of joint pain and swelling. The prefix “pseudo” means appearing like something else; the term “pseudogout” is commonly used because the symptoms of the disorder are very similar to those caused by gout. Gout is an arthritis caused by urate (sometimes referred to as uric acid) crystals. (See “Patient education: Gout (Beyond the Basics)”.)

Although the two disorders can cause similar symptoms, patients with pseudogout are treated somewhat differently than patients with gout. (See ‘Pseudogout treatment’ below.)

PSEUDOGOUT SYMPTOMS 

— Pseudogout can cause sudden attacks of pain, swelling, warmth, and difficulty using the affected joint. An attack can last for days or even weeks. The knee is affected in over 50 percent of patients with pseudogout; however, the disorder can also affect the ankles, feet, shoulders, elbows, wrists, or hands. (See “Clinical manifestations and diagnosis of calcium pyrophosphate crystal deposition (CPPD) disease”.)

PSEUDOGOUT CAUSES AND RISK FACTORS

 — Pseudogout develops in some people in response to the presence of calcium pyrophosphate dihydrate (CPP) crystals in the joints. The crystals first develop in the joint cartilage and eventually move to the lining of the joint (also called the synovium) or into the joint fluid where they cause inflammation; this causes pain, swelling, and disability in the affected joint. In most people with pseudogout, it is not known exactly why CPP crystals form and deposit in the joints. (See “Pathogenesis and etiology of calcium pyrophosphate crystal deposition (CPPD) disease”.)

Some people, particularly older adults, have CPP crystals in their joints (chondrocalcinosis) but never experience symptoms of pseudogout. Up to 50 percent of people age 90 have chondrocalcinosis. In addition to older age, there are several other factors that increase the risk of accumulating CPP crystals in the joints, including:

Joint trauma — People who have previously experienced a significant injury to or surgery on a joint have an increased risk of developing CPP crystal deposits.

Genetics — People can inherit a predisposition to CPP crystal deposition (called “familial chondrocalcinosis”); these people are more likely to develop pseudogout or other features of calcium pyrophosphate crystal deposition (CPPD) disease earlier in life.

Excess iron — People with a genetic disorder called hemochromatosis, which causes the body to store excess iron, are at an increased risk of developing CPP crystal deposits. (See “Patient education: Hemochromatosis (hereditary iron overload) (Beyond the Basics)”.)

Other related disorders — Several other diseases of metabolism or endocrine glands are associated with CPPD disease. These include hyperparathyroidism (overactive parathyroid glands), hypophosphatasia (an inherited metabolic bone disorder), hypomagnesemia (low levels of magnesium in the blood), Gitelman’s syndrome (an inherited kidney disorder), and possibly others.

PSEUDOGOUT DIAGNOSIS 

— A healthcare provider can confirm or rule out a diagnosis of pseudogout by performing an examination and tests. In many patients, a sample of joint fluid is obtained in order to determine whether calcium pyrophosphate dihydrate (CPP) crystals are present and to exclude arthritis due to other causes, such as gout or joint infection.

Synovial fluid analysis — Synovial (joint) fluid is obtained under sterile conditions through a needle inserted into the affected joint. The fluid is then analyzed to determine if CPP crystals or infection are present. The presence of CPP crystals in a patient with joint pain and inflammation suggests pseudogout, whereas urate crystals suggest gout.

Imaging (X-rays) — A healthcare provider may examine the painful joint(s) or other frequently involved joints by taking X-rays. This can reveal calcium-containing crystal deposits in the cartilage, a condition known as chondrocalcinosis.

PSEUDOGOUT COMPLICATIONS 

— Calcium pyrophosphate crystal deposition (CPPD) disease can lead to rapidly progressing osteoarthritis, caused by wearing down of the joint cartilage, bone cysts or spurs, and even fractures. These changes may occur in joints not usually involved in osteoarthritis, such as the knuckles and wrists.

Although treatment of pseudogout episodes can shorten the duration of the attack, treatment may not decrease the risk of developing a more chronic arthritis that in most ways resembles osteoarthritis. Treatment of this chronic arthritis is, thus, similar to that used for osteoarthritis. (See “Patient education: Osteoarthritis treatment (Beyond the Basics)”.)

PSEUDOGOUT TREATMENT 

— There is no treatment that can completely remove or prevent the formation of calcium pyrophosphate dihydrate (CPP) crystals. However, the joint pain and swelling generally resolve with treatment, including the following:

Joint aspiration and/or injection — A clinician may insert a needle into the affected joint to remove the fluid and crystals that have accumulated. This can help to relieve pressure and pain. An injection of glucocorticoids (steroids) into the joint may relieve the associated joint inflammation.

Oral medications — Joint aspiration or injection is usually preferred when one or two joints are affected but may not be recommended if more than two joints are affected. In this case, an oral medication, such as a nonsteroidal antiinflammatory drug (NSAID), oral glucocorticoids, or colchicine, may be preferred.

Taking an NSAID such as ibuprofen (Advil, Motrin), indomethacin (Indocin), or naproxen (Aleve, Naprosyn) can help to relieve symptoms of pain and inflammation. Prescription-strength tablets (as opposed to over-the-counter tablets) may make it more convenient to take the relatively high doses of NSAIDs that are needed to control an attack. (See “Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)”.)

Joint immobilization — Patients may be advised to avoid weight bearing (walking or running if the legs or feet are involved), to avoid excessive movement, and to limit activity for a period of time to minimize pain and swelling. In some cases, a temporary splint will be recommended to limit joint movement.

Treatment of related conditions — If the CPPD crystal deposits are caused by a separate disorder (see ‘Other related disorders’ above), that condition may require treatment, but this may not affect the course of pseudogout. (See “Treatment of calcium pyrophosphate crystal deposition (CPPD) disease”.)

PSEUDOGOUT PREVENTION 

— For patients who experience frequent episodes of pseudogout, a healthcare provider may prescribe daily colchicine. Use of this medication, which is also often used to treat or prevent gout, can reduce the number of pseudogout attacks. The benefits and risks of preventive therapy should be discussed with a healthcare provider. The cost of prophylactic use of colchicine has been an issue for many patients and their clinicians since 2010. The availability of generic colchicine preparations since early 2015 may alleviate this concern, but the impact of this action remains uncertain. One manufacturer of colchicine offers a program to defray the cost for eligible patients (ColCrys prescription assistance program [PAP] application available at: www.needymeds.org [Accessed on May 1, 2015]). (See “Patient education: Gout (Beyond the Basics)”.)

SUMMARY

Pseudogout is a form of arthritis that develops in people with deposits of calcium pyrophosphate (CPP) crystals in joints.

The symptoms of a pseudogout attack include joint pain, swelling, and warmth, often with impaired use of the affected joint. (See ‘Pseudogout symptoms’ above.)

The treatment of pseudogout is aimed at the relief of symptoms. This may include nonsteroidal antiinflammatory drugs (NSAIDs) to treat inflammation, the removal of fluid and/or injection of steroids in the joint to alleviate pressure and reduce inflammation, and/orimmobilization (rest) of the affected joint. If the pseudogout is caused by a separate disorder, treating that condition may be necessary to prevent complications of the related disease; this may, however, not affect the course of pseudogout. (See ‘Pseudogout treatment’ above.)

Some patients who suffer from frequent attacks of pseudogout may be given a medication called colchicine to help prevent future episodes. (See ‘Pseudogout prevention’ above.)

What is calcium pyrophosphate deposition disease? 

— Calcium pyrophosphate deposition disease, also called CPPD, is a type of arthritis that causes sudden attacks of joint pain and swelling. It is caused by a build-up of a type of calcium crystals (called “calcium pyrophosphate”) in the joints. Sudden attacks of CPPD used to be called “pseudogout.”

The symptoms of CPPD are similar to the symptoms of another type of arthritis, called gout. But CPPD and gout have different causes.

What are the symptoms of CPPD? 

— People with CPPD get sudden attacks of joint pain, swelling, and warmth—often in the knee. The symptoms can also happen in the ankles, feet, shoulders, elbows, wrists, and hands. Attacks can last for days or weeks.

In some people, CPPD leads to long-term osteoarthritis. Osteoarthritis is the most common type of arthritis. It causes pain and stiffness in different joints in the body. Sometimes it also causes joint swelling.

Is there a test for CPPD? 

— Yes. To check if your symptoms are caused by CPPD, your doctor will do an exam and tests. Tests can include:

Removing fluid from the painful joint – A doctor will put a needle in the joint to remove a small sample of fluid. Then he or she will look at the fluid under a microscope to see if the calcium crystals are present.

X-rays of the painful joints

Blood tests – Your doctor will do blood tests to see if you have a condition that could be causing the calcium crystals to build up.

How is CPPD treated? 

— Treatment often depends on how many joints are involved.

Doctors usually treat people who have 1 or 2 painful joints by:

Removing some fluid from the painful joint

Giving a shot of a medicine into the painful joint

Doctors usually treat people who have more than 2 painful joints with medicines called “NSAIDs.” NSAIDs are a large group of medicines that includes ibuprofen (sample brand names: Advil, Motrin), indomethacin (sample brand names: Indocin, Indocid), and naproxen (sample brand name: Aleve). If a person can’t take NSAIDs or has too many side effects from NSAIDs, other types of medicines are available. All of these treatments for CPPD help to shorten an attack and ease joint pain and swelling.

Is there anything I can do on my own? 

— Yes. Doctors usually recommend that people rest their painful joints as much as possible when an attack happens. If your doctor recommends rest, try not to move your painful joint or put weight on it.

Can CPPD attacks be prevented? 

— Sometimes. If you get a lot of attacks, your doctor might prescribe a medicine for you to take every day to help prevent future attacks. This medicine is called colchicine (brand name: Colcrys).

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