Crystal Arthritis

Dr. C. C. Visser
 Crystal Arthritis
• Gout (monosodium urate)

• Pseudogout/Chondrocalcinosis (CPPD)

• Apatite deposition disease

GOUT
 Clinical Picture
• Acute attacks of gout
• Chronic gout with/without tophi
• Kidney stones
• Renal failure
Acute gout
There is redness of the
skin of the dorsum of the
foot with marked swelling
of the entire foot and
ankle.
Tophaceous gout
Tophi involving the first,
second and fifth
metatarsophalangeal joints
with little involvement of
overlying skin.
Tophaceous gout
An ulcerating tophus of a
distal interphalangeal joint
with associated redness of
the overlying skin
Tophaceous gout
Extensive tophi of all digits
Tophaceous gout
Auricular tophi.
Tophaceous Gout
The appearance of tophi at
arthroscopy.
Tophaceous Gout
Gouty microtophi.
Multiple small tophi over
the head of a first
metatarsophalangeal joint
in a patient who had
suffered multiple attacks
of acute gout.
 Diagnosis
• Urate level

• Radiology

• Synovial fluid: MSU crystals

• Histology: MSU crystals

 Serum Urate
• Higher in males than in females

• Falsely low during an acute attack

• Range: 0,21-0,42 mmol/l

• Aim: reduce level to < 0,3 mmol/l

A large tophus is replacing
much of the fifth left
metatarsal.
• Soft tissue densities due to
tophi.
• Classical ‘punched-out’
para-articular erosion with
a sclerotic margin of the
proximal phalanx.
 Synovial fluid

Gold standard in diagnosis

Polarized light microscopy
of urate crystals.
Illustrated are extracellular
birefringent needle-shaped
urate crystals.
Polarized light microscopy
of urate crystals.
Illustrated are intracellular
birefringent needle-shaped
urate crystals.
Polarized light
microscopy. Schematic
representation of the effect
of the orientation of a
urate crystal with respect
to the direction of the
plane of slow vibration of
light when using a red-
plate compensator
(retardation plate).
 Histology

• Send sample in 100% alcohol

Synovial gouty tophus.
Synovium from a patient
with gout where the urate
crystals from the
microtophus have been
dissolved by formalin.
Polarized light microscopy
of a gouty tophus. There is
a mass of urate crystals
from a gouty tophus.
Management
 PSEUDOGOUT/
CHONDROCALCINOSIS
 Clinical presentation
• Acute attacks (pseudogout)
• Chronic arthritis
• Calcification of cartilage/soft tissues
Pseudogout affecting the
knee. Seen here in an
elderly lady with
background chronic
pyrophosphate
arthropathy. Blood-
staining of synovial fluid
is common in this
situation.
Characteristic elderly
female patient with
marked knee, wrist, and
metacarpophalangeal
pyrophosphate
arthropathy.
‘Bloody old shoulders’.
This elderly patient has
visible swellings of both
shoulders.
‘Bloody old shoulders’.
This elderly patient has
visible swellings of both
shoulders. Aspiration
revealed a large amount of
blood-stained fluid which
contained numerous
particles of basic calcium
phosphates.
 Diagnosis
• Synovial fluid: CPPD crystals

• Radiology: calcification
Synovial fluid CPPD
crystals.
Subacromial bursitis
with large effusion
Knee radiograph showing
chondrocalcinosis of both
fibrocartilage (meniscus)
and hyaline cartilage.
Knee radiograph showing
hypertrophic OA features.
Note prominant patello-
femoral involvement,
typical of pyrophosphate
arthropathy.
Hand radiograph showing
typical radiocarpal
involvement. Note
prominant cyst formation,
and CC.
Calcification affecting
metacarpophalangeal
joints.
Achilles tendon
calcification.
Anteroposterior
radiograph of the shoulder
joint showing a large
calcific deposit in the
supraspinatus tendon. The
deposit is dense,
homogenous and well-
defined, findings
characteristic of inert
calcific periarthritis.
Anteroposterior
radiograph of the shoulder
joint showing a small
periarticular calcific
deposit. Other views may
be needed to identify
small deposits and the site
of deposition.
 Treatment
• Aspirate joints
• Symptomatic relief
• Consider colchicine prophylaxis if recurrent
acute attacks
APATITE DEPOSITION
• Anteroposterior
radiographs of a shoulder
joint affected by apatite-
associated destructive
arthritis (‘Milwaukee
shoulder’). The extensive
destruction of soft tissues,
including the rotator cuff,
has led to instability of the
shoulder. Note the
extensive atrophic
destruction and loss of
bone of both the
acromium and the
glenohumeral joint.
Alizarin red S stain of an
apatite particle isolated
from the synovial fluid of
a patient with
osteoarthritis.
High magnification
transmission electron
micrographs of apatite
crystals. The crystal lattice
structure as well as the
morphology of the crystals
is apparent.
Bones from a patient with
advanced apatite
associated destructive
arthritis. The humerus
shows the extent of the
attrition and loss of bone
that can occur in this
condition. The tibial
condyles show the
characteristic destruction
of the lateral tibiofemoral
joint, with extensive loss
of subchondral bone.