Patient Case: Pseudogout (Calcium Pyrophosphate Deposition Disease – CPPD)
A 68-year-old male presents to the clinic with sudden-onset pain, swelling, and redness in his left knee for the past two days. He denies any recent trauma but reports a similar episode in the same knee six months ago that resolved within a week. He describes the pain as moderate to severe, with difficulty bearing weight on the affected leg.
Medical History & Social Background
The patient has a history of hypertension and type 2 diabetes mellitus, managed with oral medications. He has no history of rheumatoid arthritis or gout but was previously diagnosed with osteoarthritis in both knees. He does not drink alcohol and follows a relatively balanced diet.
Physical Examination
• Swollen, warm, and erythematous left knee with moderate effusion.
• Severe tenderness on palpation of the joint.
• Limited range of motion due to pain.
• No involvement of other joints.
• Afebrile, with no systemic signs of infection.
Laboratory & Imaging Findings
• Synovial fluid analysis: Positively birefringent, rhomboid-shaped calcium pyrophosphate crystals under polarized light microscopy.
• Serum uric acid: Normal.
• C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR): Mildly elevated.
• X-ray of the knee: Shows chondrocalcinosis (cartilage calcification).
Diagnosis
Based on the clinical presentation and diagnostic findings, the patient is diagnosed with acute pseudogout (Calcium Pyrophosphate Deposition Disease - CPPD) affecting the left knee.
Management Plan
1. Acute Attack Treatment
• NSAIDs (e.g., naproxen, indomethacin) for pain relief and inflammation.
• Intra-articular corticosteroid injection if symptoms persist.
• Colchicine (low-dose) for acute attack prevention in recurrent cases.
2. Long-Term Management & Prevention
• Regular joint monitoring to assess for recurrent episodes.
• Management of underlying risk factors (e.g., osteoarthritis, metabolic conditions).
• Physical therapy to maintain joint function and prevent stiffness.
3. Follow-Up & Monitoring
• Periodic joint imaging to monitor for structural changes.
• Screening for metabolic conditions, such as hyperparathyroidism, if recurrent episodes occur.
• Patient education on differentiating pseudogout from other joint conditions.
Challenges & Considerations
• Differentiating pseudogout from septic arthritis or gout in acute flare-ups.
• Coexisting osteoarthritis, which can complicate joint symptoms.
• Limited treatment options for preventing crystal deposition in the long term.
Prognosis
With appropriate acute treatment and long-term joint care, the patient can maintain good mobility. However, recurrent episodes may lead to chronic joint damage if not managed properly.
A) Gouty arthritis
B) Rheumatoid arthritis
C) Septic arthritis
D) Pseudogout (Calcium Pyrophosphate Deposition Disease - CPPD)
A) Serum uric acid level
B) Synovial fluid analysis
C) X-ray of the affected joint
D) Erythrocyte sedimentation rate (ESR)
A) Needle-shaped crystals with negative birefringence
B) Rhomboid-shaped crystals with positive birefringence
C) Large immune complexes and rheumatoid factor
D) Bacterial organisms with an elevated white blood cell count
A) Allopurinol
B) Methotrexate
C) NSAIDs (e.g., naproxen, indomethacin)
D) Hydroxychloroquine
