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Clinical Imaging and Diagnosis > Gout, CPDD and HADD > Flashcards

Gout, CPDD and HADD Flashcards

1
Q

What is Crystalline Deposit Arthritis (Gout)?

A

Uric acid crystals are deposited in joint capsules – arthritis
Manifested by hyperuricemia in combination with acute inflammatory arthritis that is usually recurrent
- arthritis induced by intra-articular deposits of monosodium urate
- aggregation of crystals = tophi  destructive arthropathy
- M/C location – Foot (Gout of foot)

Epidemiology:
- 40 yrs +
- 20 Men : 1 Woman
- ratio gets closer post menopausal and with use of diuretic medications

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2
Q

What is the classification of gout?

A

Primary - due to overproduction or the lack of excretion of uric acid d/t inborn enzymatic defect (MC type)
Secondary - due to disease or drug action

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3
Q

What are the clinical findings of Gout?

A
  • Increased ESR
    - Increased Uric Acid
    - > 6.0mg/dl (females)
    - >7.0mg/dl (males)
    - Moderate leukocytosis
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4
Q

What is stage 1 of gout?

A

Asymptomatic Hyperuricemia

  • No articular problems
  • Elevation of uric acid levels
  • Possible renal stones at this point
  • May progress to gouty arthritis or stay at this stage.
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5
Q

What is stage 2 of gout?

A

Acute Gouty Arthritis

  • acute inflammation
  • usually in the AM hours
  • most commonly in the 1st MTP, intertarsal regions, ankles, and knees
  • Up to 60% in the 1st MTP; later IP, MCP, wrists, & elbows
  • swollen hot, but dry joint.
  • rapid recovery (days - weeks) but may recur again
  • may be dormant for months - years
  • increased frequency of developing renal uric acid calculi (stones) after onset of articular attacks
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6
Q

What is the treatment/management of gout?

A
  • Affected jt placed at rest
  • Levels of uric acid reduced
  • Medications: colchicine, ACTH, and phenylbutazone
  • aspirin, diuretics, or low-calorie diets SHOULD NOT BE TAKEN as these will increase the levels of uric acid
    - Fluid intake increased to alkalize the urine
    - Purines in the diet reduced
    - Weight reduction (if overweight)
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7
Q

What are the radiological findings of gout?

A

Lag 5-10 years behind the clinical manifestations

  • Soft Tissue Changes
    • tophi (localized increase in soft tissue density)
    • lumpy bumpy- asymmetry of swelling
    • 5mm-5cm
    • eccentric
    • forearm, elbow, dorsum of hands, knee, ankle, and forefoot
    • may have calcification in or around them (not common)
  • Joint Spaces
    - preservation
    - late uniform loss in space
    - no ankylosis

Erosions:
Marginal – d/t pannus on bare areas
Periarticular
Typically at margins of the joint capsule
extrinsic pressure erosions from soft tissue tophus
metaphysis or diaphyseal
Eccentric (not central) with sclerotic margins
protruding lip of bone extending away from the bone into the soft tissues – excavation like
Leads to “ overhanging margin” sign (in approx 40%)
Intraosseous
accumulations of tophi within bone
“punched out” lesions usually within medullary cavity
MC location = subchondral bone

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8
Q

What are the radiological findings of gout in the hand?

A

Asymmetric involvement of any joint
Erosions
Soft tissue swelling
Misalignment
”Spotty carpal sign”
r/o RA
Ulnar styloid may show erosion
No OP or ulnar drift

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9
Q

What is tophi?

A

Tophi are soft tissue masses created by the deposition of urate crystals. Urate is not inherently radio-opaque. The varying densities seen on radiographs is due to calcium precipitation with the urate crystals. Tophi are typically located in the peri-articular area along the extensor surface, but maybe intra-articular or not associated with the joint at all.

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10
Q

What are radiological findings of gout in the foot?

A

1st MTP joint MC
Earliest changes include erosions of MT head, medially & dorsally
Loss of joint space is a late finding
Soft tissue swelling
eccentric
lumpy bumpy
Erosions with overhanging margins adjacent to ST tophi.
At other MTPs, esp 5th.
Punched out holes of the bones from intraosseous tophi.

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11
Q

What are the radiological findings of gout in the knee?

A

Rare knee involvement
Periarticular erosions
Soft tissue tophi and jt effusions

Intraosseous tophi result in osteolytic cyst-like lesions in patella (check lateral view for patella changes)

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12
Q

What is Calcium Pyrophosphate Crystal Deposition Disease (CPPD)?

A

A crystal deposition arthropathy involving the synovial and periarticular tissues.
Acute or chronic inflammatory arthritis.
May simulate, gout, RA, DJD or neuropathic arthropathy
may cause premature DJD (pyrophosphate arthropathy)
in spine = degenerative changes esp L-spine
peripheral = may be severe enough to simulate neuropathic jt ds.

Chondrocalcinosis: Crystals will deposit in hyaline and fibrous cartilage adjacent to chondrocytes (usually in intermediate layer and never on surface)

  1. hyaline - thin linear paralleling the articular cortex.
    - wrist, knee, elbow, hip, and shoulder
  2. fibrocartilage – thick, irregular with shaggy, poorly defined margins.
    - knee menisci, triangular fibrocartilage of wrist, symphysis pubis, and annulus

Epidemiology:
- Males=females
- Middle-aged and elderly
- Onset > 30, peak age is 60 years

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13
Q

What are the different types of calcification in Calcium Pyrophosphate Crystal Deposition Disease (CPPD)?

A
  1. Synovial calcification
    - joint margins
  2. Capsule Calcification
    - joint margins and a little displacement away from the joint
  3. Tendon and ligaments calcification
    - This linear calcification extending away from jt for variable distance
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14
Q

What are the other factors contributing to Calcium Pyrophosphate Crystal Deposition Disease (CPPD)?

A

Other factors contributing To CPPD include:
- Excess iron storage (hemochromatosis)
- Low magnesium levels in the blood (hypomagnesemia)
- An overactive parathyroid gland (hyperparathyroidism)
- A severely underactive thyroid (hypothyroidism)
- excess calcium in the blood (hypercalcemia)

JOINTS AFFECTED:
- knees> wrists> hands> ankles> hips> elbows

TENDONS AFFECTED:
- Achilles
- Triceps
- Quadriceps
- Supraspinatus

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15
Q

What are the signs and symptoms of Calcium Pyrophosphate Crystal Deposition Disease (CPPD)?

A
  • May be asymptomatic
    - Gout like symptoms in the presence of calcium pyrophosphate crystals
    - The crystals can cause inflammation, leading:
    - Swelling of the affected joint
    - Intense joint pain
    - Joint that is warm to the touch
    - Stiffness
    - Fever
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16
Q

What are the radiological findings of Calcium Pyrophosphate Crystal Deposition Disease (CPPD)?

A
  • Chondrocalcinosis = characteristic radiological finding of intraarticular fibrocartilage calcification.
    - Similar to DJD
    - loss of joint space
    - Sclerosis
    - cyst formation
    - Osteophytes
    - loose bodies
17
Q

What are the radiological findings of Calcium Pyrophosphate Crystal Deposition Disease (CPPD) in the knee?

A

MC joint

Chondrocalcinosis of the hyaline and menisci
presents as a thin dense intraarticular opacification that runs parallel and separated from the bone cortex or as a calcifying opacification in the menisci.[

Medial femorotibial > patellofemoral > lateral
isolated patellofemoral compartmental changes highly suggestive of CPPD.

DJD superimposed

18
Q

What are the radiological findings of Calcium Pyrophosphate Crystal Deposition Disease (CPPD) in the hand?

A

Predilection for the 2nd and 3rd MCP joints

Cartilage, capsular, and synovial Ca++ and arthropathy to include fragmentation

19
Q

What are the radiological findings of Calcium Pyrophosphate Crystal Deposition Disease (CPPD) in the wrist?

A

Calcification of the triangular fibrocartilage
Hyaline calcification anywhere – parallel to subchondral bone cortex

Predilection for the radiocarpal joint
decrease in space between the radius and scaphoid, with superimposed DJD

Disruption of the ligament between the scaphoid and lunate
“Terry Thomas” sign
“stepladder” appearance (worse at radiocarpal joint c.f. mid-carpal joints)
SLAC (scapholunate advanced collapse) deformity

Severe degenerative changes also common in trapezoscaphoid jt.
Always lack of changes in radioulnar compartment
(helps DDX from RA).

20
Q

What are the radiological findings of Calcium Pyrophosphate Crystal Deposition Disease (CPPD) in the shoulder?

A

Glenohumeral DJD with hyaline calcification

21
Q

What are the radiological findings of Calcium Pyrophosphate Crystal Deposition Disease (CPPD) in the spine?

A

Rare
L/S > C/S
Decrease in disc height, vacuum, sclerosis, osteophytes, and facet arthropathy.
Annular calcification

22
Q

What are the radiological findings of Calcium Pyrophosphate Crystal Deposition Disease (CPPD) in the symphysis pubis?

A

Vertical linear Ca++ in jt fibrocartilage with assoc degenerative changes

23
Q

What is Hydroxyapatite Deposition Disease (HADD)?

A

Idiopathic
A systemic disease of unknown etiology, caused by para-articular and/or intra-articular deposition of HA crystals.

4 stages:
Pre-calcific - HA crystals begin to envelop the affected structure
Calcific - HA crystals seen as dense, uniform calcifications on X-rays
Resorptive - calcifications start to liquify and seep out of the tendon, causing pain
Post-calcific - the calcifications disappear.

Epidemiology:
- Males > Females - General
- Females > Males - Shoulder
- 40 – 60 years age (Ave Age 45 yoa)

24
Q

What are the clinical findings of Hydroxyapatite Deposition Disease (HADD)?

A
  • NO lab features
    - Self limiting
    - Most definitive method of DX is radiographic findings of Ca++
    - MC one joint, but may be multiple
    - Affects sedentary individuals more frequently than manual laborers
    - May be associated with repetitive activity or microtrauma typical for degenerative tendinopathy
      - M/C seen in  tendons 
      - Occurs at a short distance from insertion -  slightly away from the cortex of the bone

  - MC site – Shoulder rotator cuff
      - hip > spine > fingers > elbow > wrist > knee > ankle tendons
25
Q

What are the clinical findings of Hydroxyapatite Deposition Disease (HADD)?

A
  • Pain
    - Tenderness
    - Inflammation
    - Local swelling
    - Poss Fever
    - Decreased ROM
      - 15% asymptomatic – HADD = incidental finding
26
Q

What are the radiological findings of Hydroxyapatite Deposition Disease (HADD)?

A

Radiological Findings:

	- Starts as an amorphous density
	- Progresses to more homogenous, well defined, round to oval calcification at site of tendon or bursa = Best Diagnostic Clue
	- May progress or disappear

	- The appearance will vary based on the calcific stage: Formative and resting phases - appear as round-to-ovoid calcification in the soft tissue with well-defined borders Resorptive phase - appear ill-defined with a comet tail-like appearance.
                                  - may mimic a periosteal reaction

Clinical Imaging and Diagnosis (16 decks)

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