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Sapundzhieva T, Sapundzhiev L, Batalov A. Practical Use of Ultrasound in Modern Rheumatology-From A to Z. Life (Basel) 2024; 14:1208. [PMID: 39337990 PMCID: PMC11433054 DOI: 10.3390/life14091208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Revised: 09/15/2024] [Accepted: 09/20/2024] [Indexed: 09/30/2024] Open
Abstract
During the past 20 years, the use of ultrasound (US) in rheumatology has increased tremendously, and has become a valuable tool in rheumatologists' hands, not only for assessment of musculoskeletal structures like joints and peri-articular tissues, but also for evaluation of nerves, vessels, lungs, and skin, as well as for increasing the accuracy in a number of US-guided aspirations and injections. The US is currently used as the imaging method of choice for establishing an early diagnosis, assessing disease activity, monitoring treatment efficacy, and assessing the remission state of inflammatory joint diseases. It is also used as a complementary tool for the assessment of patients with degenerative joint diseases like osteoarthritis, and in the detection of crystal deposits for establishing the diagnosis of metabolic arthropathies (gout, calcium pyrophosphate deposition disease). The US has an added value in the diagnostic process of polymyalgia rheumatica and giant-cell arteritis, and is currently included in the classification criteria. A novel use of US in the assessment of the skin and lung involvement in connective tissue diseases has the potential to replace more expensive and risky imaging modalities. This narrative review will take a close look at the most recent evidence-based data regarding the use of US in the big spectrum of rheumatic diseases.
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Affiliation(s)
- Tanya Sapundzhieva
- Department of Propedeutics of Internal Diseases, Faculty of Medicine, Medical University of Plovdiv, 4001 Plovdiv, Bulgaria; (L.S.); (A.B.)
- Rheumatology Department, University Hospital ‘Pulmed’, 4002 Plovdiv, Bulgaria
| | - Lyubomir Sapundzhiev
- Department of Propedeutics of Internal Diseases, Faculty of Medicine, Medical University of Plovdiv, 4001 Plovdiv, Bulgaria; (L.S.); (A.B.)
- Rheumatology Department, University Hospital ‘Pulmed’, 4002 Plovdiv, Bulgaria
| | - Anastas Batalov
- Department of Propedeutics of Internal Diseases, Faculty of Medicine, Medical University of Plovdiv, 4001 Plovdiv, Bulgaria; (L.S.); (A.B.)
- Rheumatology Clinic, University Hospital ‘Kaspela’, 4000 Plovdiv, Bulgaria
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Gessl I, Sakellariou G, Wildner B, Filippou G, Mandl P, D'Agostino MA, Navarro-Compán V. Systematic literature review to inform the EULAR recommendations for the use of imaging in crystal-induced arthropathies in clinical practice. Ann Rheum Dis 2024; 83:1208-1224. [PMID: 38702175 DOI: 10.1136/ard-2023-225247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 04/02/2024] [Indexed: 05/06/2024]
Abstract
OBJECTIVE To summarise current data regarding the use of imaging in crystal-induced arthropathies (CiAs) informing a European Alliance of Associations for Rheumatology task force. METHODS We performed four systematic searches in Embase, Medline and Central on imaging for diagnosis, monitoring, prediction of disease severity/treatment response, guiding procedures and patient education in gout, calcium pyrophosphate dihydrate deposition (CPPD) and basic calcium phosphate deposition (BCPD). Records were screened, manuscripts reviewed and data of the included studies extracted. The risk of bias was assessed by validated instruments. RESULTS For gout, 88 studies were included. Diagnostic studies reported good to excellent sensitivity and specificity of dual-energy CT (DECT) and ultrasound (US), high specificity and lower sensitivity for conventional radiographs (CR) and CT. Longitudinal studies demonstrated sensitivity to change with regard to crystal deposition by US and DECT and inflammation by US and structural progression by CR and CT. For CPPD, 50 studies were included. Diagnostic studies on CR and US showed high specificity and variable sensitivity. There was a single study on monitoring, while nine assessed the prediction in CPPD. For BCPD, 56 studies were included. There were two diagnostic studies, while monitoring by CR and US was assessed in 43 studies, showing a reduction in crystal deposition. A total of 12 studies with inconsistent results assessed the prediction of treatment response. The search on patient education retrieved two studies, suggesting a potential role of DECT. CONCLUSION This SLR confirmed a relevant and increasing role of imaging in the field of CiAs.
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Affiliation(s)
- Irina Gessl
- Division of Rheumatology, Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Garifallia Sakellariou
- Department of Internal Medicine and Therapeutics, Università di Pavia, Pavia, Italy
- Istituti Clinici Scientifici Maugeri SpA SB IRCCS, Pavia, Italy
| | | | - Georgios Filippou
- Rheumatology, IRCCS Ospedale Galeazzi - Sant'Ambrogio, Milan, Italy
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Peter Mandl
- Division of Rheumatology, Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Maria Antonietta D'Agostino
- Rheumatology Department, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, IRCSS, Rome, Italy
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Pascart T, Filippou G, Lioté F, Sirotti S, Jauffret C, Abhishek A. Calcium pyrophosphate deposition disease. THE LANCET. RHEUMATOLOGY 2024:S2665-9913(24)00122-X. [PMID: 39089298 DOI: 10.1016/s2665-9913(24)00122-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 05/01/2024] [Accepted: 05/03/2024] [Indexed: 08/03/2024]
Abstract
Calcium pyrophosphate deposition (CPPD) disease is a consequence of the immune response to the pathological presence of calcium pyrophosphate (CPP) crystals inside joints, which causes acute or chronic inflammatory arthritis. CPPD is strongly associated with cartilage degradation and osteoarthritis, although the direction of causality is unclear. This clinical presentation is called CPPD with osteoarthritis. Although direct evidence is scarce, CPPD disease might be the most common cause of inflammatory arthritis in older people (aged >60 years). CPPD is caused by elevated extracellular-pyrophosphate concentrations in the cartilage and causes inflammation by activation of the NLRP3 inflammasome. Common risk factors for CPPD disease include ageing and previous joint injury. It is uncommonly associated with metabolic conditions (eg, hyperparathyroidism, haemochromatosis, hypomagnesaemia, and hypophosphatasia) and genetic variants (eg, in the ANKH and osteoprotegerin genes). Apart from the detection of CPP crystals in synovial fluid, imaging evidence of CPPD in joints by mainly conventional radiography, and increasingly ultrasonography, has a central role in the diagnosis of CPPD disease. CT is useful in showing calcification in axial joints such as in patients with crowned dens syndrome. To date, no treatment is effective in dissolving CPP crystals, which explains why control of inflammation is currently the main focus of therapeutic strategies. Prednisone might provide the best benefit-risk ratio for the treatment of acute CPP-crystal arthritis, but low-dose colchicine is also effective with a risk of mild diarrhoea. Limited evidence suggests that colchicine, low-dose weekly methotrexate, and hydroxychloroquine might be effective in the prophylaxis of recurrent flares and in the management of persistent CPP-crystal inflammatory arthritis. Additionally, biologics inhibiting IL-1 and IL-6 might have a role in the management of refractory disease.
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Affiliation(s)
- Tristan Pascart
- Department of Rheumatology, Saint-Philibert Hospital, ETHICS Laboratory, Lille Catholic University, Lille, France.
| | - Georgios Filippou
- Department of Rheumatology, IRCCS Galeazzi-Sant'Ambrogio Hospital, Milan, Italy; Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Frédéric Lioté
- Feel'Gout, Department of Rheumatology, GH Paris Saint-Joseph, Paris, France; UMR 1132 Bioscar, Inserm, Université Paris Cité, Centre Viggo Petersen, Lariboisière Hospital, Paris, France
| | - Silvia Sirotti
- Department of Rheumatology, IRCCS Galeazzi-Sant'Ambrogio Hospital, Milan, Italy
| | - Charlotte Jauffret
- Department of Rheumatology, Saint-Philibert Hospital, ETHICS Laboratory, Lille Catholic University, Lille, France
| | - Abhishek Abhishek
- Academic Rheumatology, University of Nottingham, Nottingham, UK; NIHR Nottingham Biomedical Research Centre, Nottingham, UK
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Pascart T, Robinet P, Ottaviani S, Leroy R, Segaud N, Pacaud A, Grandjean A, Luraschi H, Rabin T, Deplanque X, Maciejasz P, Visade F, Mackowiak A, Baclet N, Maréchaux S, Lefebvre A, Budzik JF, Bardin T, Richette P, Norberciak L, Ducoulombier V, Houvenagel E. Evaluating the safety and short-term equivalence of colchicine versus prednisone in older patients with acute calcium pyrophosphate crystal arthritis (COLCHICORT): an open-label, multicentre, randomised trial. THE LANCET. RHEUMATOLOGY 2023; 5:e523-e531. [PMID: 38251496 DOI: 10.1016/s2665-9913(23)00165-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/07/2023] [Accepted: 06/13/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Acute calcium pyrophosphate crystal arthritis causes intense joint pain mainly affecting older people. Because guidance and evidence remain scarce, management of this disease relies on expert opinion. We therefore aimed to compare the safety and short-term equivalence of low-dose colchicine with oral prednisone in older patients with acute calcium pyrophosphate crystal arthritis. METHODS We did an open-label, multicentre, randomised, trial (COLCHICORT) at six hospitals in Paris and northern France. We enrolled patients who were admitted to hospital who were 65 years or older and who presented with acute calcium pyrophosphate crystal arthritis with a symptom duration of less than 36 h. Diagnosis of calcium pyrophosphate crystal arthritis was made by the identification of calcium pyrophosphate crystals on synovial fluid analysis or typical clinical presentation (onset of joint pain and swelling). Key exclusion criteria included absence of calcium pyrophosphate crystals on synovial fluid analysis or a history of gout. Participants were randomly allocated (1:1), using a centralised electronic treatment group allocation module, to receive either colchicine 1·5 mg on day 1 and 1 mg on day 2 (ie, the colchicine group) or oral prednisone 30 mg on days 1 and 2 (ie, the prednisone group). The primary outcome was change in joint pain (measured by visual analogue scale [VAS] from 0 mm to 100 mm) at 24 h. Equivalence was determined whether the 95% CI of the between-group difference at 24 h was within the -13 mm to +13 mm margin in the per-protocol analysis. Adverse events were recorded using the National Cancer Institute Common Terminology Criteria for Adverse Events (version 4.0). This trial is completed and is registered with ClinicalTrials.gov, NCT03128905. FINDINGS Between Feb 5, 2018, and May 7, 2022, 111 patients who were admitted to hospital were randomly assigned (57 [51%] to the colchicine group and 54 [49%] to the prednisone group). 95 (86%) of 111 patients were included in the per-protocol analysis (49 [52%] in the colchicine group and 46 [48%] in the prednisone group). The median age was 88·0 years (IQR 82·0-91·0) and 69 (73%) of 95 participants were women and 26 (27%) were men. Acute calcium pyrophosphate crystal arthritis affected mainly the knee in 46 (48%) of 95 participants, the wrist in 19 (20%), and the ankle in 12 (13%). Pain VAS at baseline was 68 mm (SD 17). At 24 h, change in pain VAS was -36 mm (SD 32) in the colchicine group and -38 mm (SD 23) in the prednisone group. The between-group difference in change in pain VAS at 24 h was -1 mm (95% CI -12 to 10), showing equivalence between the two drugs. In the colchicine group, 12 (22%) of 55 patients had diarrhoea, one (2%) had hypertension, and none had hyperglycaemia. In the prednisone group, three (6%) of 54 had diarrhoea, six (11%) had hypertension, and three (6%) had hyperglycaemia. No deaths occurred in the colchicine group; two deaths occurred in the prednisone group, which were deemed unrelated to prednisone (one due to infectious valvular endocarditis leading to heart failure, and one due to a stroke). INTERPRETATION Colchicine and prednisone exhibit equivalent short-term efficacy for the treatment of acute calcium pyrophosphate crystal arthritis, with different safety profiles in the older population. FUNDING French Inter-regional Hospital Program of Clinical Research.
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Affiliation(s)
- Tristan Pascart
- Department of Rheumatology, Hôpital Saint-Philibert, Université Catholique de Lille, Lomme, France.
| | - Pierre Robinet
- Department of Geriatrics, Hôpital Saint-Philibert, Université Catholique de Lille, Lomme, France
| | | | - Rémi Leroy
- Department of Rheumatology, Centre Hospitalier de Dunkerque, Dunkirk, France
| | - Nicolas Segaud
- Department of Internal Medicine, Centre Hospitalier d'Armentières, Armentières, France
| | - Aurore Pacaud
- Department of Rheumatology, Hôpital Saint-Philibert, Université Catholique de Lille, Lomme, France
| | - Agathe Grandjean
- Department of Rheumatology, Hôpital Saint-Philibert, Université Catholique de Lille, Lomme, France
| | - Hélène Luraschi
- Department of Rheumatology, Hôpital Saint-Vincent-de-Paul, Université Catholique de Lille, Lille, France
| | - Thibault Rabin
- Department of Rheumatology, Hôpital Saint-Philibert, Université Catholique de Lille, Lomme, France
| | - Xavier Deplanque
- Department of Geriatrics, Hôpital Saint-Vincent-de-Paul, Université Catholique de Lille, Lille, France
| | - Pierre Maciejasz
- Department of Geriatrics, Hôpital Saint-Vincent-de-Paul, Université Catholique de Lille, Lille, France
| | - Fabien Visade
- Department of Geriatrics, Hôpital Saint-Philibert, Université Catholique de Lille, Lomme, France
| | - Alexandre Mackowiak
- Department of Neurology, Hôpital Saint-Philibert, Université Catholique de Lille, Lomme, France
| | - Nicolas Baclet
- Department of Internal Medicine, Hôpital Saint-Vincent-de-Paul, Université Catholique de Lille, Lille, France
| | - Sylvestre Maréchaux
- Department of Cardiology, Hôpital Saint-Philibert, Université Catholique de Lille, Lomme, France
| | - Antoine Lefebvre
- Department of Pharmacy, Hôpital Saint-Philibert, Université Catholique de Lille, Lomme, France
| | - Jean-François Budzik
- Department of Radiology, Hôpital Saint-Philibert, Université Catholique de Lille, Lomme, France
| | - Thomas Bardin
- Department of Rheumatology, Hôpital Lariboisière APHP Paris Nord, INSERM, UMR 1132, Bioscar, Paris, France
| | - Pascal Richette
- Department of Rheumatology, Hôpital Lariboisière APHP Paris Nord, INSERM, UMR 1132, Bioscar, Paris, France
| | - Laurène Norberciak
- Research Department-Biostatistics and Methodology, Hôpital Saint-Philibert, Université Catholique de Lille, Lomme, France
| | - Vincent Ducoulombier
- Department of Rheumatology, Hôpital Saint-Philibert, Université Catholique de Lille, Lomme, France
| | - Eric Houvenagel
- Department of Rheumatology, Hôpital Saint-Philibert, Université Catholique de Lille, Lomme, France
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Cowley S, McCarthy G. Diagnosis and Treatment of Calcium Pyrophosphate Deposition (CPPD) Disease: A Review. Open Access Rheumatol 2023; 15:33-41. [PMID: 36987530 PMCID: PMC10040153 DOI: 10.2147/oarrr.s389664] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
Calcium Pyrophosphate Dihydrate (CPPD) crystal-related arthropathies are a common cause of acute and chronic arthritis caused by the deposition of calcium pyrophosphate crystals in joints and soft tissues, resulting in inflammation and joint damage. They present with a wide spectrum of clinical manifestations and often present challenges to diagnosis and management as they commonly affect older co-morbid patients. The challenges are compounded by a lack of a well-defined description of CPPD. However, an international expert-driven process is underway to develop CPPD classification criteria. Treatment is also problematic as unlike gout, there are no agents available that decrease the crystal burden. Treatment options have often been extrapolated from gout treatment pathways without having extensive trials or a solid evidence base. It is hoped the new CPPD classification guidelines will contribute to large multicentre studies, with well-defined patient cohorts, which will facilitate the production of high-quality evidence to guide the management of this condition. Here, we discuss the barriers and facilitators in diagnosing and treating CPPD-related arthropathy.
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Affiliation(s)
- Sharon Cowley
- Department of Rheumatology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Geraldine McCarthy
- Department of Rheumatology, Mater Misericordiae University Hospital, Dublin, Ireland
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Adinolfi A, Sirotti S, Sakellariou G, Cipolletta E, Filippucci E, Porta F, Zanetti A, Ughi N, Sarzi-Puttini P, Scirè CA, Keen H, Pineda C, Terslev L, D’Agostino MA, Filippou G. Which are the most frequently involved peripheral joints in calcium pyrophosphate crystal deposition at imaging? A systematic literature review and meta-analysis by the OMERACT ultrasound – CPPD subgroup. Front Med (Lausanne) 2023; 10:1131362. [PMID: 36968827 PMCID: PMC10034772 DOI: 10.3389/fmed.2023.1131362] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 02/09/2023] [Indexed: 03/11/2023] Open
Abstract
ObjectivesTo identify the prevalence of calcium pyrophosphate crystal deposition (CPPD) using ultrasound and conventional radiology at peripheral joints in patients with suspected or definite CPPD.MethodsA systematic literature search was performed in PubMed and Embase using pre-defined search strategies from inception to April 2021 to identify studies that evaluated conventional radiology and ultrasound in detecting CPPD at peripheral joints, including definite or suspected CPPD [Research question 1 (RQ1) and Research Question 2 (RQ2), respectively]. For the meta-analysis, the first, second, and third sub-analysis included studies with the knee, and knee or wrist as the index joint for CPPD (without restrictions on the reference standard) and synovial fluid analysis or histology as a reference standard (without restrictions on the index joint), respectively.ResultsOne-thousand eight hundred and twenty-seven manuscripts were identified, of which 94 articles were finally included. Twenty-two and seventy-two papers were included in RQ1 and RQ2, respectively. The knee had the highest prevalence for RQ1 and RQ2 by both conventional radiology and ultrasound, followed by the wrist with the highest prevalence for RQ1. The hand had the lowest CPPD prevalence. The third sub-analysis showed a higher CPPD prevalence on ultrasound than conventional radiology at the knee (only data available).ConclusionAmong all peripheral joints, the knees and wrists could be regarded as the target joints for CPPD detection by imaging. Furthermore, ultrasound seems to detect a higher number of calcium pyrophosphate deposits than conventional radiology, even when using a more restrictive reference standard.
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Affiliation(s)
- Antonella Adinolfi
- Rheumatology Division, Multispecialist Medical Department, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- *Correspondence: Antonella Adinolfi,
| | - Silvia Sirotti
- IRCCS Ospedale Galeazzi – Sant’Ambrogio, Rheumatology Department, Milan, Italy
| | - Garifallia Sakellariou
- Department of Internal Medicine and Therapeutics, Università di Pavia, Pavia, Italy
- Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Edoardo Cipolletta
- Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Emilio Filippucci
- Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Francesco Porta
- Interdisciplinary Pain Medicine Unit, Rheumatology Section, Santa Maria Maddalena Hospital, Rovigo, Italy
| | | | - Nicola Ughi
- Rheumatology Division, Multispecialist Medical Department, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- SIR Epidemiology, Research Unit, Milan, Italy
| | - Piercarlo Sarzi-Puttini
- IRCCS Ospedale Galeazzi – Sant’Ambrogio, Rheumatology Department, Milan, Italy
- Department of Biomedical and Clinical Sciences, Università degli studi di Milano, Milan, Italy
| | - Carlo Alberto Scirè
- SIR Epidemiology, Research Unit, Milan, Italy
- School of Medicine, University of Milano Bicocca, Milan, Italy
| | - Helen Keen
- Medicine and Pharmacology Department, The University of Western Australia, Murdoch, Perth, WA, Australia
| | - Carlos Pineda
- Rheumatology Department, Instituto Nacional de Rehabilitacion, Mexico, Mexico
| | - Lene Terslev
- Center for Rheumatology and Spine Diseases, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | | | - Georgios Filippou
- IRCCS Ospedale Galeazzi – Sant’Ambrogio, Rheumatology Department, Milan, Italy
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Mank VMF, Goldstein E, Babb S, Meghpara S, Breighner C, Roberts J. 20 Years of Radiographic Imaging: Crystalline Deposits Causing Severe Arthropathy and Erosions. Mil Med 2023; 188:e432-e435. [PMID: 33826727 DOI: 10.1093/milmed/usab129] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/22/2021] [Accepted: 03/27/2021] [Indexed: 01/11/2023] Open
Abstract
Urate crystal gout arthritis and calcium pyrophosphate deposition disease (CPPD) are crystalline arthropathies seen in middle age to elderly patients, but are also seen in the active duty military population. Flares of either can be identified by acute joint pain, associated swelling, tenderness, and warmth. Definitive diagnosis involves synovial analysis from arthrocentesis. Gout and CPPD are common inflammatory joint diseases. Both arthropathies presenting themselves in the same joint are rather rare. An elderly female with a history of gout presented to the hospital with severe hip pain. She was on urate-lowering therapy at the time, and uric acid levels on admission were not significantly elevated. Radiographic imaging of her hip demonstrated periarticular cartilage calcifications. A review of radiographic imaging over the last 20 years found significant erosive arthropathy in multiple joints and radiographic evidence of chondrocalcinosis, suggesting CPPD. Synovial analysis was not obtained during this admission as the patient declined procedures due to her elderly age. Her condition improved with oral steroids. Few literatures have demonstrated that gout and CPPD are common crystal arthropathies that can occur concomitantly in the same joint. A 20-year review of imaging in an elderly female with known gout arthropathy found that she had radiographic evidence of concomitant CPPD-associated damage to many of her joints. Clinicians should be aware of the different erosive arthropathies, their corresponding imaging findings, evaluation for underlying metabolic disorders if appropriate, and the possibility that they may occur in the same joint. Early prevention can reduce joint destruction later in life.
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Affiliation(s)
- Victoria M F Mank
- Department of Internal Medicine, Tripler Army Medical Center, Honolulu, HI 96859, USA
| | - Elianna Goldstein
- Department of Radiology, Tripler Army Medical Center, Honolulu, HI 96859, USA
| | - Sean Babb
- Department of Internal Medicine, Tripler Army Medical Center, Honolulu, HI 96859, USA
| | - Sanket Meghpara
- Department of Internal Medicine, Tripler Army Medical Center, Honolulu, HI 96859, USA
| | - Crystal Breighner
- Department of Internal Medicine, Tripler Army Medical Center, Honolulu, HI 96859, USA
| | - Jefferson Roberts
- Department of Rheumatology, Tripler Army Medical Center, Honolulu, HI 96859, USA
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OUP accepted manuscript. Rheumatology (Oxford) 2022; 61:3997-4005. [DOI: 10.1093/rheumatology/keac063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/17/2022] [Indexed: 11/14/2022] Open
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Abstract
PURPOSE OF REVIEW Calcium pyrophosphate deposition disease (CPPD) arises from calcium pyrophosphate deposition throughout the body, leading to different clinical syndromes that may be diagnosed using various imaging modalities. The purpose of this review is to highlight recent updates in the imaging of CPPD. RECENT FINDINGS Conventional radiography remains the initial test when imaging CPPD; but musculoskeletal ultrasound and conventional computed tomography (CT) may also assist in diagnosing and characterizing CPP deposits, with increased sensitivity. Dual-energy CT is also being used to differentiate CPP crystals from other crystal deposition diseases. CPP discitis has been diagnosed with MRI, but MRI has lower sensitivity and specificity than the aforementioned imaging studies in CPPD diagnosis. Assorted imaging modalities are increasingly used to diagnose CPPD involving atypical joints, avoiding invasive procedures. Each modality has its advantages and disadvantages. Future imaging may be able to provide more utility than what is currently available.
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Pfeil A. Calcium pyrophosphate crystal deposition in Gitelman syndrome: which joint is affected? Rheumatology (Oxford) 2021; 61:2211-2212. [PMID: 34554234 DOI: 10.1093/rheumatology/keab705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/07/2021] [Accepted: 09/09/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Alexander Pfeil
- Department of Internal Medicine III, Jena University Hospital-Friedrich Schiller University Jena, Jena, Germany
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The diagnostic value of conventional radiography and musculoskeletal ultrasonography in calcium pyrophosphate deposition disease: a systematic literature review and meta-analysis. Osteoarthritis Cartilage 2021; 29:619-632. [PMID: 33577959 DOI: 10.1016/j.joca.2021.01.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 01/06/2021] [Accepted: 01/19/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To examine and compare the accuracy of conventional radiography (CR) and musculoskeletal ultrasonography (US) in the diagnosis of calcium pyrophosphate (CPP) crystals deposition disease (CPPD). DESIGN A systematic search of electronic databases (PubMed, Embase, and Cochrane), conference abstracts and reference lists was undertaken. Studies which evaluated the accuracy of CR and/or US in the diagnosis of CPPD, using synovial fluid analysis (SFA), histology or classification criteria as reference tests were included. Subgroup analyses by anatomic site and by reference test were performed. RESULTS Twenty-six studies were included. Using SFA/histology as reference test, CR and US showed an excellent (CR AUC = 0.889, 95%CI = 0.811-0.967) and an outstanding (US AUC = 0.954, 95%CI = 0.907-1.0) diagnostic accuracy (p < 0.01), respectively. Furthermore, US showed a higher sensitivity (0.85, 95%CI = 0.79-0.90 vs 0.47, 95%CI = 0.40-0.55) and only a little lower specificity (0.87, 95%CI = 0.83-0.91 vs 0.95, 95%CI = 0.92-0.97) than CR. A considerable heterogeneity between the studies was found, with adopted reference test being the main source of heterogeneity. In fact, subgroup analysis showed a significant change in the diagnostic accuracy of CR, but not of US, using Ryan and McCarty criteria or SFA/histology as reference test (CR: AUC = 0.956, 95%CI = 0.925-1.0 vs AUC = 0.889, 95%CI = 0.828-0.950, respectively, p < 0.01) (US: AUC = 0.922, 95%CI = 0.842-1.0 vs AUC = 0.957, 95%CI = 0.865-1.0, respectively, p = 0.08) CONCLUSIONS: Although US is more sensitive and a little less specific than CR for identifying CPP crystals, both these two techniques showed a great diagnostic accuracy and should be regarded as complementary to each other in the diagnostic work-up of patients with CPPD.
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A critical review of the available evidence on the diagnosis and clinical features of CPPD: do we really need imaging? Clin Rheumatol 2020; 40:2581-2592. [PMID: 33231775 DOI: 10.1007/s10067-020-05516-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/14/2020] [Accepted: 11/16/2020] [Indexed: 02/08/2023]
Abstract
Imaging has been playing an important role in the pathogenetic and clinical characterisation of many rheumatic diseases, especially in the most recent years with the advent of many new, highly technological and promising techniques. Calcium pyrophosphate deposition disease (CPPD) benefited also from these new techniques, most of which can readily identify calcium crystals. Nowadays, imaging is used mainly to identify crystals in joints but given the complexity of CPPD, imaging should be used with an "holistic" approach in order to gain insights in the pathogenesis, spectrum of clinical manifestations and natural history of the disease. Furthermore, overlap or association of CPPD with other prevalent diseases of the elderly makes the differential diagnosis challenging. In this review, we provide a critical review of the current knowledge on the use of imaging both for the identification of crystals and for its application in clinical practice as an aid for determining the impact of the disease on patients.Key Points• CPPD is a complex disease with a wide spectrum of clinical manifestations and understanding of pathogenetic mechanisms and clinical phenotypes is essential for correct characterisation• Imaging has made important advances regarding identification of CPPD in recent years, and new, more sophisticated techniques are under investigation• Imaging has the potential to improve our knowledge on pathogenesis and clinical phenotypes of CPPD• Imaging techniques have to be tested thoroughly for reliability, discrimination and sensitivity to change before they can be implemented in clinical trials.
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Filippucci E, Reginato AM, Thiele RG. Imaging of crystalline arthropathy in 2020. Best Pract Res Clin Rheumatol 2020; 34:101595. [PMID: 33012644 DOI: 10.1016/j.berh.2020.101595] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Crystal-related arthropathies are the result of crystal deposition in joint and periarticular soft tissues. Identification of urate crystals is mandatory to distinguish gout from other crystalline arthropathies, including calcium pyrophosphate dihydrate and basic calcium phosphate crystal deposition diseases. ACR/EULAR classification criteria for gout included dual-energy computed tomography and ultrasound with equal impact to the final score. Different diagnostic strengths of these imaging modalities depend on disease duration and scanned anatomic site. While ultrasound has been indicated as the first-choice imaging technique, especially in the early stages of the disease, dual-energy computed tomography has shown to be highly specific, allowing the detection of crystal deposits in anatomic sites not accessible by ultrasound, such as the spine. At the spinal level, MRI findings are usually nonspecific. Finally, there is preliminary evidence that at the knee, dual-energy computed tomography may discriminate calcium pyrophosphate dihydrate from basic calcium phosphate crystal deposits.
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Affiliation(s)
- Emilio Filippucci
- Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, "Carlo Urbani" Hospital, Jesi, Ancona, Italy.
| | - Anthony M Reginato
- Division of Rheumatology, Department of Dermatology, The Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Ralf G Thiele
- Division of Allergy, Immunology and Rheumatology, Department of Medicine, University of Rochester, Rochester, NY, USA.
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Cipolletta E, Smerilli G, Mashadi Mirza R, Di Matteo A, Carotti M, Salaffi F, Grassi W, Filippucci E. Sonographic assessment of calcium pyrophosphate deposition disease at wrist. A focus on the dorsal scapho-lunate ligament. Joint Bone Spine 2020; 87:611-617. [PMID: 32438060 DOI: 10.1016/j.jbspin.2020.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 04/24/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To investigate the diagnostic accuracy of ultrasound and conventional radiography in the evaluation of calcium pyrophosphate crystal deposits at wrist level. METHODS Consecutive patients with a "definite" diagnosis of calcium pyrophosphate deposition disease and disease-controls were prospectively included in this cross-sectional single-centre study. Scapho-lunate ligament, triangular fibrocartilage complex, and volar recess of the radio-lunate joint were explored using ultrasound, conventional radiography and computed tomography. RESULTS Sixty one patients and 39 disease controls were enrolled. Two-hundred wrists were evaluated using both conventional radiography and ultrasound and 26 using computed tomography. Ultrasound findings indicative of crystal deposits were found in at least one wrist in 95.1% of patients and in 15.4% of controls (P<0.001). Scapho-lunate ligament calcifications were reported in 83.6% of patients and in 5.1% of controls (P<0.001). On conventional radiography, calcifications were found in at least one wrist in 72.1% of patients and in 0% of controls (P<0.001). Using the Ryan-McCarty criteria as a gold standard, sensitivity, specificity and diagnostic accuracy were 0.72 (0.59-0.83), 1.0 (0.91-1.0) and 0.83 (0.74-0.90) for conventional radiography and 0.95 (0.86-0.99), 0.85 (0.69-0.94) and 0.91 (0.84-0.96) for ultrasound. The agreement between ultrasound and computed tomography was substantial when assessing triangular fibrocartilage complex (kappa=0.70; 0.43-0.97) and scapho-lunate ligament (kappa=0.69; 0.41-0.97), and moderate for radio-lunate joint (kappa=0.46; 0.12-0.80). CONCLUSIONS This study supports the diagnostic accuracy of ultrasound in evaluating wrist involvement in calcium pyrophosphate deposition disease. The inclusion of the scapho-lunate ligament in a disease-oriented scanning protocol could improve the diagnostic performance of ultrasound.
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Affiliation(s)
- Edoardo Cipolletta
- Polytechnic University of Marche, Department of Clinical and Molecular Sciences, Rheumatology Unit, "Carlo Urbani" Hospital, Via Aldo Moro 25, Jesi 60035, Italy.
| | - Gianluca Smerilli
- Polytechnic University of Marche, Department of Clinical and Molecular Sciences, Rheumatology Unit, "Carlo Urbani" Hospital, Via Aldo Moro 25, Jesi 60035, Italy
| | - Riccardo Mashadi Mirza
- Azienda Ospedali Riuniti Marche Nord, Radiology Department, Piazzale Carlo Cinelli, 1, Pesaro 61121, Italy
| | - Andrea Di Matteo
- Polytechnic University of Marche, Department of Clinical and Molecular Sciences, Rheumatology Unit, "Carlo Urbani" Hospital, Via Aldo Moro 25, Jesi 60035, Italy; University of Leeds, Leeds Institute of Rheumatic and Musculoskeletal Medicine, Woodhouse Lane, Leeds LS2 9JT, United Kingdom
| | - Marina Carotti
- Polytechnic University of Marche, Radiology Department, Via Conca 71, Ancona 60126, Italy
| | - Fausto Salaffi
- Polytechnic University of Marche, Department of Clinical and Molecular Sciences, Rheumatology Unit, "Carlo Urbani" Hospital, Via Aldo Moro 25, Jesi 60035, Italy
| | - Walter Grassi
- Polytechnic University of Marche, Department of Clinical and Molecular Sciences, Rheumatology Unit, "Carlo Urbani" Hospital, Via Aldo Moro 25, Jesi 60035, Italy
| | - Emilio Filippucci
- Polytechnic University of Marche, Department of Clinical and Molecular Sciences, Rheumatology Unit, "Carlo Urbani" Hospital, Via Aldo Moro 25, Jesi 60035, Italy
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Sakellariou G, Scirè CA, Adinolfi A, Batticciotto A, Bortoluzzi A, Delle Sedie A, De Lucia O, Dejaco C, Epis OM, Filippucci E, Idolazzi L, Picchianti Diamanti A, Zabotti A, Iagnocco A, Filippou G. Differential Diagnosis of Inflammatory Arthropathies by Musculoskeletal Ultrasonography: A Systematic Literature Review. Front Med (Lausanne) 2020; 7:141. [PMID: 32457913 PMCID: PMC7221062 DOI: 10.3389/fmed.2020.00141] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 03/31/2020] [Indexed: 12/27/2022] Open
Abstract
Background: Differential diagnosis in early arthritis is challenging, especially early after symptom onset. Several studies applied musculoskeletal ultrasound in this setting, however, its role in helping diagnosis has yet to be clearly defined. The purpose of this work is to systematically assess the diagnostic applications of ultrasonography in early arthritis in order to summarize the available evidence and highlight possible gaps in knowledge. Methods: In December 2017, existing systematic literature reviews (SLR) on rheumatoid arthritis (RA), osteoarthritis (OA), psoriatic arthritis (PsA), polymyalgia rheumatica (PMR), calcium pyrophosphate deposition disease (CPPD), and gout were retrieved. Studies on ultrasound to diagnose the target conditions and detecting elementary lesions (such as synovitis, tenosynovitis, enthesitis, bone erosions, osteophytes) were extracted from the SLRs. The searches of the previous reviews were updated and data from new studies fulfilling the inclusion criteria extracted. Groups of reviewers worked separately for each disease, when possible diagnostic accuracy (sensitivities, specificities) was calculated from primary studies. When available, the reliability of ultrasound to detect elementary lesions was extracted. Results: For all the examined disease, recent SLRs were available. The new searches identified 27 eligible articles, with 87 articles included from the previous SLRs. The diagnostic performance of ultrasound in identifying diseases was addressed by 75 studies; in most of them, a single elementary lesion was used to define diagnosis, except for PMR. Only studies on RA included consecutive patients with new onset of arthritis, while studies on gout and CPPD often focused on subjects with mono-arthritis. Most of the remaining studies enrolled patients with a defined diagnosis. Synovitis was the most frequently detected lesion; clinical diagnosis was the most common reference standard. The diagnostic performance of ultrasound across different conditions was extremely variable. Ultrasound to identify elementary lesions was assessed in 38 studies in OA, gout and CPPD. Its performance in OA was very variable, with better results in CPPD and gout. The reliability of ultrasound was moderate to good for most lesions. Conclusions: Although a consistent amount of literature investigated the diagnostic application of ultrasound, in only a minority of cases its additional value over clinical diagnosis was tested. This SLR underlines the need for studies with a pragmatic design to identify the placement of ultrasound in the diagnostic pathway of new-onset arthritis.
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Affiliation(s)
- Garifallia Sakellariou
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Carlo Alberto Scirè
- UOC e Sezione di Reumatologia - Dipartimento di Scienze Mediche, Università degli Studi di Ferrara, Ferrara, Italy.,Società Italiana di Reumatologia, Unità Epidemiologica, Milan, Italy
| | | | - Alberto Batticciotto
- Rheumatology Unit, Department of Internal Medicine, ASST-Settelaghi, "Ospedale di Circolo - Fondazione Macchi", Varese, Italy
| | - Alessandra Bortoluzzi
- UOC e Sezione di Reumatologia - Dipartimento di Scienze Mediche, Università degli Studi di Ferrara, Ferrara, Italy
| | | | - Orazio De Lucia
- Unit of Clinical Rheumatology, Department of Rheumatology and Clinical Sciences, ASST Centro Traumatologico Ortopedico G. Pini - CTO, Milan, Italy
| | - Christian Dejaco
- Department of Rheumatology, Medical University of Graz, Graz, Austria.,Department of Rheumatology, Hospital of Bruneck, Bruneck, Italy
| | | | - Emilio Filippucci
- Rheumatology Unit, Department of Clinical and Molecular Sciences, Carlo Urbani Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Luca Idolazzi
- Rheumatology Unit, Ospedale Civile Maggiore, University of Verona, Verona, Italy
| | - Andrea Picchianti Diamanti
- Department of Clinical and Molecular Medicine, S. Andrea University Hospital, "Sapienza" University, Rome, Italy
| | - Alen Zabotti
- Department of Medical and Biological Science, Rheumatology Clinic, Azienda Sanitaria Universitaria Integrata, Udine, Italy
| | - Annamaria Iagnocco
- Academic Rheumatology Centre, Università degli Studi di Torino, Turin, Italy
| | - Georgios Filippou
- UOC e Sezione di Reumatologia - Dipartimento di Scienze Mediche, Università degli Studi di Ferrara, Ferrara, Italy
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Di Matteo A, Filippucci E, Cipolletta E, Musca A, Carotti M, Mashadi Mirza R, Jesus D, Martire V, Pierucci D, Di Carlo M, Salaffi F, Grassi W. Hip Involvement in Patients With Calcium Pyrophosphate Deposition Disease: Potential and Limits of Musculoskeletal Ultrasound. Arthritis Care Res (Hoboken) 2019; 71:1671-1677. [DOI: 10.1002/acr.23814] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 11/16/2018] [Indexed: 12/12/2022]
Affiliation(s)
| | | | | | - Alice Musca
- Dr. I. Cantacuzino Clinical Hospital Bucharest Romania
| | | | | | - Diogo Jesus
- Centro Hospitalar e Universitario de Coimbra Coimbra Portugal
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Lee KA, Lee SH, Kim HR. Diagnostic value of ultrasound in calcium pyrophosphate deposition disease of the knee joint. Osteoarthritis Cartilage 2019; 27:781-787. [PMID: 30738145 DOI: 10.1016/j.joca.2018.11.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 10/02/2018] [Accepted: 11/05/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the diagnostic performance of ultrasound (US) for calcium pyrophosphate deposition (CPPD) at the level of menisci, hyaline cartilage (HC), tendons, and synovial fluid (SF) of the knee, and to examine inter- and intra-observer reliability. DESIGN We consecutively included patients with knee effusion over a 2-year period (43 patients with CPPD and 131 controls). All patients underwent SF analysis, conventional radiography (CR), and US examination using the Outcome Measures in Rheumatology (OMERACT) definition of the US characteristics of CPPD. Two independent operators performed the US, and inter-observer agreement was calculated. Intra-observer agreement was examined with static images obtained for all enrolled patients. RESULTS US revealed calcium pyrophosphate (CPP) deposits in menisci, HC, and tendon more frequently in patients with CPPD than in control patients. The presence of US CPP deposits in SF was not significantly different between the two groups. Combined US evaluation of the three components (menisci, HC, and tendon) showed the best diagnostic performance. The sensitivity and specificity for US evaluation of the three components were 74.4% and 77.1%, respectively, while for CR evaluation, the sensitivity and specificity were 44.2% and 96.9%, respectively. Inter- and intra-observer agreement were excellent for medial (κ = 0.930, 0.972) and lateral menisci (κ = 0.905, 0.942), HC (κ = 0.844, 0.957), and SF (κ = 0.817, 0.925). Tendon showed fair inter-observer (κ = 0.532) and good intra-observer reliability (κ = 0.788). CONCLUSIONS Based on the OMERACT definition, US demonstrated better diagnostic capacity than CR to diagnose CPPD, with excellent reliability. Combined evaluation of menisci, HC, and tendon showed the best diagnostic accuracy.
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Affiliation(s)
- K-A Lee
- Division of Rheumatology, Department of Internal Medicine, Research Institute of Medical Science, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, South Korea.
| | - S-H Lee
- Division of Rheumatology, Department of Internal Medicine, Research Institute of Medical Science, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, South Korea.
| | - H-R Kim
- Division of Rheumatology, Department of Internal Medicine, Research Institute of Medical Science, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, South Korea.
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Zell M, Zhang D, FitzGerald J. Diagnostic advances in synovial fluid analysis and radiographic identification for crystalline arthritis. Curr Opin Rheumatol 2019; 31:134-143. [PMID: 30601230 PMCID: PMC6377265 DOI: 10.1097/bor.0000000000000582] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW The present review addresses diagnostic methods for crystalline arthritis including synovial fluid analysis, ultrasound, and dual energy CT scan (DECT). RECENT FINDINGS There are new technologies on the horizon to improve the ease, sensitivity, and specificity of synovial fluid analysis. Raman spectroscopy uses the spectral signature that results from a material's unique energy absorption and scatter for crystal identification. Lens-free microscopy directly images synovial fluid aspirate on to a complementary metal-oxide semiconductor chip, providing a high-resolution, wide field of view (∼20 mm) image. Raman spectroscopy and lens-free microscopy may provide additional benefit over compensated polarized light microscopy synovial fluid analysis by quantifying crystal density in synovial fluid samples. Ultrasound and DECT have good sensitivity and specificity for the identification of monosodium urate (MSU) and calcium pyrophosphate (CPP) crystals. However, both have limitations in patients with recent onset gout and low urate burdens. SUMMARY New technologies promise improved methods for detection of MSU and CPP crystals. At this time, limitations of these technologies do not replace the need for synovial fluid aspiration for confirmation of crystal detection. None of these technologies address the often concomitant indication to rule out infectious arthritis.
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Affiliation(s)
- Monica Zell
- David Geffen School of Medicine, University of California at Los Angeles, Department of Medicine
| | - Dawen Zhang
- David Geffen School of Medicine, University of California at Los Angeles, Department of Medicine
| | - John FitzGerald
- David Geffen School of Medicine, University of California at Los Angeles, Department of Medicine
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