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Types of Arthritis

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J.R.A.
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D.I.S.H.
Gout
Pseudogout
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Reiterís syndrome
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Paget's Disease
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The Role of Sports and Activity in Osteoarthritis
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Pseudogout

            Both gout and pseudogout are types of arthritis that are caused by crystal deposition in the affected joint or joints.  Gout is caused by the deposition of uric acid crystals.  Pseudogout is caused by the deposition of calcium pyrophosphate crystals in the affected joint or joints.  Pseudogout is sometimes termed calcium pyrophosphate disease (CPPD).  Like gout, pseudogout typically presents with the sudden onset of a painful, hot, and very tender joint.  Pseudogout most commonly affects the knee, wrist, and shoulder joints and gout most commonly affects the small joint at the base of the big toe, and the ankle, wrist and knee joints.  The only definitive way to distinguish the gout from pseudogout is by aspirating the joint fluid and analyzing the type of crystal in the joint.  In fact, it was only in 1962 that scientists realized pseudogout was a distinct entity from gout.

The chance of getting pseudogout increases with age and occurs slightly more commonly in men (1.5x more common in men than in women).   As with gout, the pain from gout results from the deposition of crystals (in this case crystals made of caclcium pyrophosphate) stimulating an inflammatory reaction in the body.  It is not currently known why some people develop pseudogout and others do not.  Intake of calcium is not associated with pseudogout.  Pseudogout has been associated with aging, previous trauma to the affected joint, and certain metabolic diseases (hyperparathyroidism, hypothryoidisim, and hemachromatosis).  While, the exact relationship between gout and these factors has not been clearly delineated, anyone diagnosed with pseudogout should have their parathyroid hormone, thyroid hormone and blood iron levels checked as well as other blood chemistry tests. 

 

How is pseudogout diagnosed?

            Pseudogout is diagnosed in much the same way as gout is diagnosed.  The first piece of the diagnosis is the clinical presentation of the painful joint or joints.  As previously mentioned, pseudogout typically presents with a hot, swollen, very painful, extremely tender knee, wrist, or shoulder joint.  However, any joint can be affected by pseudogout.  Typically only one joint is painful at a time.  Symmetrical involvement of joints on both sides of the body makes pseudogout less likely.  Left untreated, the symptoms may persist for days to weeks.  After resolving, an attack of pseudogout may recur months or years later.  Risk factors for pseudogout, including age, medical history and previous trauma to the joint are also part of the clinical picture when making the diagnosis.

            Blood tests may reveal blood chemistry abnormalities, however if positive these may reflect an underlying metabolic disorder but will not make the immediate diagnosis of pseudogout.

            Ultimately, as previously mentioned, the diagnosis of pseudogout, like gout, rests on performing an arthrocentesis in which joint fluid is aspirated under sterile conditions and the joint fluid is analyzed with a polarizing microscope.  In pseudogout, calcium pyrophosphate crystals are found. 

            X-ray and MRI may be obtained to rule out other causes of the pain and/or to evaluate the extent of disease and possible damage to bone and surrounding structures, however they are not diagnostic of pseudogout. 

 

How is pseudogout treated?

            An acute attack of pseudogout is treated primarily by raising the affected joint, applying ice, relieving pressure from the joint, giving oral medications, and/or injecting the joint with steroid.  Oral medications to treat an acute attack of pseudogout include non-steroidal anti‑inflammatory drugs (NSAIDs) and steroids.  NSAIDs such as ibuprofen, indomethacin, and naproxen are effective first-line medications.  The most common risks include stomach problems, increased blood pressure, and kidney problems.  When NSAIDs, are not effective or cannot be tolerated by the patient, oral prednisone is an alternative.

            Oral prednisone can also be given to treat an acute attack of pseudogout.  Side effects from a short course of prednisone include irritability, increased blood pressure, increased susceptibility to infection, puffy face, insomnia, euphoria, mood swings, personality changes, headache, and facial flushing. 

            Occasionally, narcotic medication may be necessary for pain control when other medications are ineffective. 

            As with gout, a diagnostic arthrocentesis can also be therapeutic for an acute of pseudogout.  In addition, also as with gout, if the index of suspicion for an infected joint (called septic arthritis) is extremely low then cortisone can be injected after aspirating the fluid.  However, if septic arthritis cannot be ruled out by the appearance of the joint fluid and clinical presentation, then your doctor will have to wait to inject cortisone as injecting into a potentially infected joint can have a disastrous result.  Once joint fluid examination is performed and the diagnosis of gout is confirmed, an injection of cortisone can greatly reduce a painful attack of gouty arthritis.  For pseudogout, triamcinolone (another form of steroid) is often used in the injection instead of cortisone.

            Once the acute attack of pseudogout has been treated the focus becomes on preventing further attacks.  Allopurinol and other medications that are used as prophylactic treatment for gout work by decreasing circulating uric acid levels and so are not effective for preventing pseudogout.  There is no medication that has been shown to prevent further pseudogout attacks.  However, if an underlying metabolic abnormality is detected (hyperparathyroidism, hypothyroidism, or hemochromatosis) then treating the metabolic abnormality may prevent further pseudogout attacks.

 Some physicians believe that colchicine, which is a medication that inhibits the inflammatory response and is commonly used in the treatment of gout, may be used for treatemtn of acute pseudogout and that small doses of chronic colchicines may help prevent subsequent attacks of pseudogout.  The most common side effect of colchicine is stomach problems.  All patients that take colchicine over extended periods of time require blood monitoring because of the rare but serious possible side effect of damage to the bone marrow.  Colchicine can also cause hair loss, weakness, and nerve problems.

            All patients should stay active and participate in exercise programs that emphasize stretching and strengthening the joints and surrounding muscles.  Patients with a history of pseudogout should make every effort to stay well hydrated as dehydration may precipitate a recurrent attack of pseudogout.

             

           

 

 

 

 

 

 Arthritis MD. © 2005