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Mitani K, Minami M, Takahashi T, Toyoda M, Kanematsu R, Hanakita J. Acute cervical epidural abscess with concurrent calcium pyrophosphate deposition after cervical spinal surgery: A case report. Surg Neurol Int 2024; 15:87. [PMID: 38628534 PMCID: PMC11021091 DOI: 10.25259/sni_740_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 02/17/2024] [Indexed: 04/19/2024] Open
Abstract
Background Spinal epidural abscess (SEA) is a rare condition that may result in catastrophic outcomes. On the other hand, calcium pyrophosphate (CPP) deposition disease (CPPD) causes inflammatory arthritis. Spinal involvement of a crystal-induced inflammation caused by CPPD is also common. Surgery is a common risk factor for both SEA and CPPD; however, the postoperative acute onset of SEA complicated with CPPD is extremely rare. Case Description A man in his 70s presented to our hospital, complaining of right upper limb weakness, loss of dexterity, and gait disturbance. The diagnosis of cervical spondylotic myelopathy was made, and he performed laminectomy at C3, C4, and C5 levels. Four days after the laminectomy, he suffered from acute neck pain, weakness, and hypoesthesia in his arms and legs. Magnetic resonance imaging revealed a mass occupying the dorsal epidural space of C6 and C7, compressing the cervical spinal cord. Considering the acute symptomatology, an acute spinal epidural hematoma after surgery was suspected; therefore, emergency C6 and C7 laminectomy was performed. Surgical findings indicated that the pressure inside the spinal canal was elevated, and the mass was purulent exudate. Pathological examination showed suppurative inflammation with concomitant deposition of CPP. SEA complicated with CPPD was considered; therefore, antibiotics and non-steroidal anti-inflammatory drugs were administered. The motor weakness and hypoesthesia were improved despite a slight residual deficit in his dexterity. Conclusion An acute onset of SEA complicated with CPPD after cervical surgery has rarely been reported. The suppurative inflammation fostered by the crystal-induced inflammation may account for the acute symptomatology.
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Affiliation(s)
- Koki Mitani
- Spinal Disorders Center, Fujieda Heisei Memorial Hospital, Fujieda, Japan
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Gupta SR, Cherukuri SPS, Chehab M, Paudel K, Haas C. Pseudogout of the lumbar spine. Radiol Case Rep 2023; 18:1490-1493. [PMID: 36747909 PMCID: PMC9898284 DOI: 10.1016/j.radcr.2022.10.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/12/2022] [Accepted: 10/23/2022] [Indexed: 02/05/2023] Open
Abstract
Calcium pyrophosphate deposition involves deposition of calcium pyrophosphate dihydrate crystals in various joints throughout the body. The term "pseudogout" refers to an acute attack of calcium pyrophosphate crystal-induced arthritis. Though clinical presentation and joint involvement vary, involvement of the lumbar spine is rare. We present the case of a 61-year-old male who presented with 3 days of worsening lower back pain. He had elevated inflammatory markers, leukocytosis, and spinal tenderness on exam. Magnetic resonance imaging of the lumbar spine showed likely L4-L5 osteomyelitis; however, biopsy of the disk space revealed extensive calcium pyrophosphate crystal deposition. The patient was treated with prednisone taper with alleviation of symptoms. Though pseudogout of the spine is rare, our report supports literature urging clinicians to consider pseudogout when assessing elderly patients with back pain for prompt and appropriate treatment.
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Affiliation(s)
- Sneha R. Gupta
- Medstar Health Internal Medicine Residency Program, 3700 Toone Street, Apt 2622, Baltimore, MD 21224, USA,Corresponding author.
| | - Sai Phani Sree Cherukuri
- Medstar Health Internal Medicine Residency Program, 3700 Toone Street, Apt 2622, Baltimore, MD 21224, USA
| | - Mohamad Chehab
- Medstar Health Internal Medicine Residency Program, 3700 Toone Street, Apt 2622, Baltimore, MD 21224, USA,Medstar Health Hospitalist Program, Baltimore, MD, USA
| | - Kalyan Paudel
- Medstar Health Department of Radiology, Baltimore, MD, USA
| | - Christopher Haas
- Medstar Health Internal Medicine Residency Program, 3700 Toone Street, Apt 2622, Baltimore, MD 21224, USA,Department of Internal Medicine, Georgetown University School of Medicine, Washington, DC, USA
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Ben Tekaya A, Nacef L, Bellil M, Saidane O, Rouached L, Bouden S, Tekaya R, Mahmoud I, Abdelmoula L. Lumbar Spinal Involvement in Calcium Pyrophosphate Dihydrate Disease: A Systematic Literature Review. Int J Gen Med 2022; 15:7639-7656. [PMID: 36226310 PMCID: PMC9550172 DOI: 10.2147/ijgm.s360714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/27/2022] [Indexed: 11/06/2022] Open
Abstract
Background Calcium-pyrophosphate-dihydrate-disease (CPPD) is a crystal-induced arthropathy. The lumbar-spinal involvement is rare and often under-diagnosed. This study aimed to report the case of a lumbar spine CPPD involvement and to perform a systematic review of clinical, imaging features of lumbar involvement in CPPD patients, and treatments that have been implemented. Methods This systematic review was conducted in accordance with the Preferred-Reporting-Items-for-Systematic-Reviews and Meta-Analyses (PRISMA) guidelines. Results One hundred and sixty-seven articles met the search criteria using electronic databases searches. We retained 28 articles (20 case reports, 2 case series, 1 family survey, 4 retrospective studies, and 1 prospective study) involving a total of 62 patients. The age ranged between 39 and 89 years old. Among patients with lumbar spine CPPD, 32 were women. The duration of symptoms varied between one day and 8 years. The affection has been discovered during back pain in most cases. In 5 studies, the diagnosis was made on histological specimens of patients operated on for another pathology. X-ray showed calcifications in 2 cases. CT-scan detected calcium deposit in 7 cases. MRI showed lesions going from the increased signal of the disk, to calcified or not-cystic lesion of the facet joints, an intramedullary mass mimicking a schwannoma. Histological examination established the diagnosis of CPPD in 21 patients in all studies. Medical treatment included NSAIDs, Colchicine, Interleukin-1-receptor-antagonist, and antibiotics. Surgery was performed on 13 patients and allowed to establish the histological diagnosis. Conclusion In the case of inflammatory back pain in elderly subjects, without an infectious gateway, diagnosis of CPPD should be considered, especially for patients with a history of spinal surgery or degenerative radiography changes. CT scan is more sensitive than conventional radiographs. The discovertebral biopsy is the Gold-Standard and should be performed whenever the diagnosis was uncertain. Treatment includes the medical and surgical components.
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Affiliation(s)
- Aicha Ben Tekaya
- Rheumatology Department, Charles Nicolle Hospital, Tunis, Tunisia,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia,Correspondence: Aicha Ben Tekaya, Rheumatology Department, Charles Nicolle Hospital, Tunis, Tunisia, Tel +216 97850485, Email
| | - Lilia Nacef
- Rheumatology Department, Charles Nicolle Hospital, Tunis, Tunisia,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Mehdi Bellil
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia,Orthopedic Department, Charles Nicolle Hospital, Tunis, Tunisia
| | - Olfa Saidane
- Rheumatology Department, Charles Nicolle Hospital, Tunis, Tunisia,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Leila Rouached
- Rheumatology Department, Charles Nicolle Hospital, Tunis, Tunisia,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Selma Bouden
- Rheumatology Department, Charles Nicolle Hospital, Tunis, Tunisia,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Rawdha Tekaya
- Rheumatology Department, Charles Nicolle Hospital, Tunis, Tunisia,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Ines Mahmoud
- Rheumatology Department, Charles Nicolle Hospital, Tunis, Tunisia,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Leila Abdelmoula
- Rheumatology Department, Charles Nicolle Hospital, Tunis, Tunisia,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
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Mizutomi K, Ryu Y, Sugimori N, Okamura T, Hayashi H, Kawai H. A case of inflammatory mass resulting from calcium crystal deposition disease around the thoracic spine. Radiol Case Rep 2022; 17:4769-4773. [PMID: 36212763 PMCID: PMC9535289 DOI: 10.1016/j.radcr.2022.09.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/04/2022] [Accepted: 09/11/2022] [Indexed: 11/05/2022] Open
Abstract
Calcium crystal deposition diseases are transient benign diseases that can cause intense pain. They can sometimes cause masses and soft tissue edema around the calcification, which should be differentiated from tumors and abscesses. We report a case of calcium crystal deposition disease with an enhanced mass on the ventral side of the vertebral bodies resembling tumors and abscesses. A female patient in her 50s visited our hospital complaining of chest pain. Computed tomography revealed a soft tissue mass with polygonal high-density lesions on the ventral side of the thoracic spine. Initially, we suspected it to be a perivertebral tumor and considered a biopsy. However, the pain rapidly improved with the administration of oral acetaminophen (Caronal, Chuo-ku/Tokyo/Japan). Hence, the patient was followed up for the time being. The mass disappeared after 3 months. In addition, polygonal high-density lesions inside the mass disappeared over time. Therefore, it was diagnosed as an inflammatory mass due to calcium crystal deposition disease. Calcium crystal deposition diseases can cause soft tissue edema and inflammatory mass around the calcium crystal deposit that can be confused with a perivertebral tumor. This report elucidates the importance of identifying calcifications within and near the masses to diagnose an inflammatory mass resulting from calcium crystal deposition.
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Affiliation(s)
- Kaori Mizutomi
- Department of Radiology, Tonami General Hospital, Toyama, Japan,Corresponding author.
| | - Yasuji Ryu
- Department of Radiology, Tonami General Hospital, Toyama, Japan
| | | | - Toshiyuki Okamura
- Department of Internal Medicine, Tonami General Hospital, Toyama, Japan
| | - Hiroyuki Hayashi
- Department of Orthopedics, Tonami General Hospital, Toyama, Japan
| | - Hiroshi Kawai
- Department of Internal Medicine, Tonami General Hospital, Toyama, Japan
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Muacevic A, Adler JR. A Case of Pseudogout Causing Thoracic Myelopathy. Cureus 2022; 14:e30258. [PMID: 36381947 PMCID: PMC9653015 DOI: 10.7759/cureus.30258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2022] [Indexed: 01/25/2023] Open
Abstract
Calcium pyrophosphate deposition disease is not an uncommon cause of polyarthritis, especially in the elderly. This disease typically affects the appendicular skeleton but may rarely affect the axial skeleton as well. When the axial skeleton is involved, it can lead to numerous neurological signs and can be disabling. We describe a case in which a 68-year-old male presented with on-and-off myelopathy and was thought to have chronic inflammatory demyelinating polyneuropathy. Magnetic resonance imaging of the spine suggested an inflammatory or infectious lesion at the thoracic level. However, after a surgical biopsy, pathologists concluded that calcium pyrophosphate deposition, or pseudogout, was the cause of this patient's neurological symptoms. Pseudogout in the spine, especially the thoracic spine, is exceptionally rare. There are very few additional cases reported. In this report, we review the current literature on existing similar cases, radiological findings, risk factors, and treatments for this condition in hopes of increasing knowledge and awareness of this rare differential.
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Jaffee S, Jeong SW, Dabecco R, Elhamdani S, Yu A. Pseudogout, an unconventional imitator of the lumbosacral spine with associated chronic epidural hematoma: illustrative cases. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21571. [PMID: 36130549 PMCID: PMC9379621 DOI: 10.3171/case21571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/20/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Pseudogout, or calcium pyrophosphate dihydrate (CPPD) disease, is an inflammatory joint disease that most commonly involves the joints of the knees, ankles, and wrists. Pseudogout has also been known to involve the spine, especially the atlanto-occipital joint of the cervical spine, but there is limited documentation of its involvement in the lumbar spine. Though the atypical presentation of spinal pseudogout with findings consistent with discitis and epidural abscess has been documented, its presentation with associated chronic spinal epidural hematoma is a rare entity. OBSERVATIONS The authors present two separate cases of pseudogout involvement of the lumbar spine, one case presenting with a clinical and radiographic picture consistent with discitis and epidural abscess and the other with radiographic and operative findings consistent with a chronic epidural hematoma. LESSONS This case series demonstrates rare and atypical presentations of pseudogout within the lumbosacral spine.
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Affiliation(s)
- Stephen Jaffee
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Seung Won Jeong
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Rocco Dabecco
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Shahed Elhamdani
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Alexander Yu
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
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7
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Nakayama Y, Ohta R, Mouri N, Sano C. Intercostal Muscle Abscesses in Infective Endocarditis Associated With Migratory Deposition of Calcium Pyrophosphate. Cureus 2022; 14:e21396. [PMID: 35198303 PMCID: PMC8856648 DOI: 10.7759/cureus.21396] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2022] [Indexed: 11/05/2022] Open
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Kleyer A, Roemer F, Schett G, Manger B. Differenzialdiagnose Rückenschmerzen mit Entzündungsparametern: Fallvorstellung: Manifestation einer CPPD als Crowned Dens Syndrom mit Befall peripherer Gelenke. AKTUEL RHEUMATOL 2021. [DOI: 10.1055/a-1327-1424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
ZusammenfassungDer aktuelle Fall beschreibt den Fall eines 84 jährigen Patienten mit zunächst unklaren Rückenschmerzen und hohen Entzündungsparameter. Nach Ausschluss infektiöser Ursache konnte im Verlauf eine CPPD (Calcium pyrophosphat deposition disease) Erkrankung mit Wirbelsäulenbefall diagnostiziert werden. Neue radiologische Segmentierungsverfahren erlaubten zudem die Detektion von CPPD Kristallen in peripheren Gelenken. Nach Gabe von Prednisolon und Kineret konnte die Beschwerdesymptomatik erfolgreich behandelt werden.
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Affiliation(s)
- Arnd Kleyer
- Rheumatologie, Universitätsklinikum Erlangen, Medizinische Klinik 3, Rheumatologie und Immunologie, Erlangen, Deutschland
| | - Frank Roemer
- Radiologie, Universitätsklinikum Erlangen, Radiologisches Institut, Erlangen, Deutschland
| | - Georg Schett
- Rheumatologie, Universitätsklinikum Erlangen, Medizinische Klinik 3, Rheumatologie und Immunologie, Erlangen, Deutschland
| | - Bernhard Manger
- Rheumatologie, Universitätsklinikum Erlangen, Medizinische Klinik 3, Rheumatologie und Immunologie, Erlangen, Deutschland
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Ryu S, Kim YJ, Lee S, Ryu J, Park S, Hong JU. Pathophysiology and MRI Findings of Infectious Spondylitis and the Differential Diagnosis. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2021; 82:1413-1440. [PMID: 36238882 PMCID: PMC9431966 DOI: 10.3348/jksr.2021.0138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/25/2021] [Accepted: 11/21/2021] [Indexed: 11/25/2022]
Abstract
MRI에서 추간판의 이상 신호와 위, 아래 척추체 종판의 파괴, 종판 주변의 골수부종 등은 감염성 척추염의 전형적인 소견으로 여겨지나 퇴행성 척추질환, acute Schmorl's node, 척추관절병증, synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO)/chronic recurrent multifocal osteomyelitis, 척추신경관절병증, calcium pyrophosphate dehydrate 결절침착질환 등 다양한 비감염성 척추질환에서도 나타날 수 있다. MRI에서 이러한 비감염성 척추질환과 감별되는 감염성 척추염의 영상 소견은 추간판의 고신호와 농양, 척추 연부조직의 농양, 그리고 T1 강조영상에서 저신호로 보이는 종판의 경계가 불명확해지는 점 등이다. 그러나 이러한 감별점이 항상 적용되는 것은 아니며 감염성, 비감염성 질환의 영상 소견에 유사점이 많기 때문에 정확한 진단을 위해서는 감염성 척추염뿐만 아니라 감염과 감별해야 하는 다양한 질환의 병태생리와 연관된 영상학적 특징을 아는 것이 중요하다.
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Affiliation(s)
- Sunjin Ryu
- Department of Radiology, Hanyang University School of Medicine, Seoul Hospital, Seoul, Korea
| | - Yeo Ju Kim
- Department of Radiology, Hanyang University School of Medicine, Seoul Hospital, Seoul, Korea
| | - Seunghun Lee
- Department of Radiology, Hanyang University School of Medicine, Seoul Hospital, Seoul, Korea
| | - Jeongah Ryu
- Department of Radiology, Hanyang University School of Medicine, Guri Hospital, Guri, Korea
| | - Sunghoon Park
- Department of Radiology, Ajou University School of Medicine, Suwon, Korea
| | - Jung Ui Hong
- Department of Radiology, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
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Chang DG, Park JB, Jung HY, Seo KJ. Cervical myelopathy due to subaxial calcium pyrophosphate dihydrate (CPPD) deposition with simultaneous asymptomatic crowned dens syndrome: two case reports. BMC Musculoskelet Disord 2020; 21:713. [PMID: 33129302 PMCID: PMC7603775 DOI: 10.1186/s12891-020-03736-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/23/2020] [Indexed: 11/20/2022] Open
Abstract
Background There are few reports of cervical myelopathy caused by an attack of subaxial calcium pyrophosphate dihydrate (CPPD) deposition. Moreover, there has been no report on cervical myelopathy by subaxial CPPD deposition with simultaneous asymptomatic crowned dens syndrome (CDS) at the same time. Case presentation The first case was a 68-year-old male complaining of cervical myelopathic symptoms. Plain radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) findings revealed spinal cord compression by calcified round lesions at C4 as well as a calcified lesion behind the dens. The second case was a 77-year-old female complaining of cervical myelopathic symptoms. Plain radiographs, CT and MRI findings revealed spinal cord compression by calcified round lesions at C3 and C4 as well as a calcified lesion behind the dens. In both cases, we believed that the calcified lesion behind the dens was an asymptomatic lesion. Therefore, the first patient received decompressive laminectomy of C3 and C4, removal of calcified round lesions, and posterior fixation from C3 to C5 due to associated kyphosis. The second patient underwent decompressive laminectomy of C3 and C4 and removal of calcified round lesions. Microscopic examination under polarized light showed dark blue calcifications with rhomboid crystals that were positively birefringent. The findings were consistent with those of CPPD. Conclusions This is the first study to report cervical myelopathy caused by subaxial CPPD deposition with simultaneous asymptomatic CDS. Surgical removal of the subaxial CPPD deposition alone achieved a satisfactory surgical outcome without recurrence.
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Affiliation(s)
- Dong-Gune Chang
- Department of Orthopaedic Surgery, Inje University Sanggye Paik Hospital, College of Medicine, Inje University, Seoul, South Korea
| | - Jong-Beom Park
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, South Korea. .,Department of Orthopaedic Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 271 Cheonbo-ro, Uijeongbu-si, Gyeonggi-do, 11765, South Korea.
| | - Ho-Young Jung
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Kyung Jin Seo
- Department of Pathology, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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Vanni D, Berjano P. Spinal pseudogout is a joker. Commentary on "Calcium pyrophosphate deposition disease of the cervical and thoracolumbar spine: A report of two cases". NORTH AMERICAN SPINE SOCIETY JOURNAL 2020; 3:100028. [PMID: 35141596 PMCID: PMC8820059 DOI: 10.1016/j.xnsj.2020.100028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 06/14/2023]
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Moon AS, Mabry S, Pittman JL. Calcium pyrophosphate deposition disease of the cervical and thoracolumbar spine: A report of two cases. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2020; 3:100026. [PMID: 35141594 PMCID: PMC8819963 DOI: 10.1016/j.xnsj.2020.100026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/09/2020] [Accepted: 08/17/2020] [Indexed: 11/30/2022]
Abstract
Background Spinal calcium pyrophosphate deposition disease (CPPD) is uncommon, and often resembles more common spine pathologies causing pain and neural compression. Here, we present two unusual cases of CPPD of the cervical and thoracolumbar spines. Case description Case 1: A 71-year old female smoker presented with a large epidural mass causing rapidly progressive cervical myelopathy with weakness in the upper and lower extremities. Case 2: A 66-year-old morbidly obese male presented with chronic back pain for several years associated with progressively worsening radicular pain in his left lower extremity. Outcome The first case is an example of tumoral CPPD involving the facet joint and expanding into the epidural space. The second case was an example of CPPD involving a thoracolumbar facet cyst, resulting in unilateral radiculopathy. Both patients were treated surgically and had significant improvement in symptoms post-operatively. Conclusions CPPD in the spine is an uncommon diagnosis but should be considered in the differential diagnosis of patients presenting with back pain and associated neurological symptoms. Accurate diagnosis of spinal CPPD is important in that it will guide postoperative management with anti-inflammatory medications and reduce risk of recurrence.
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Acute Attack of Pseudogout with the Wide Lesion in Lumbar Spondylolytic Spondylolisthesis. Case Rep Orthop 2020; 2020:4512695. [PMID: 32802536 PMCID: PMC7411475 DOI: 10.1155/2020/4512695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 07/02/2020] [Accepted: 07/18/2020] [Indexed: 12/04/2022] Open
Abstract
Objective To report a rare case of an acute attack of calcium pyrophosphate dihydrate (CPPD) deposition disease in a patient with lumbar spondylolytic spondylolisthesis, which demonstrated widespread lesion with neurological deficit. Methods An 86-year-old woman presented with high fever and bilateral neurological deficit of the lower extremities. Results CRP was elevated (20.9 mg/dl). Plain radiographs and computed tomography images showed bilateral L4 spondylolytic spondylolisthesis. Sagittal magnetic resonance (MR) images revealed effusion at the L3-4 interspinous space, and a gadolinium- (GD-) enhanced epidural mass was observed at the level of L4 vertebral body. Axial MR images showed an intra- or epidural lesion at L2-3. Moreover, epidural GD-enhanced masses compressed the dural sac in the shape of a cross at the L3-4 and L4-5 segments. The patient was suspected of having pyogenic arthritis of the lumbar spine in initial diagnosis. A total of 1.2 ml of fluid with a murky, pus-like synovial effusion was aspirated from the L3-4 interspinous space under the fluoroscopic image. Smear speculum of synovial fluid tested negative for bacteria and fungi; however, a number of crystals were seen. Based on the result of smear speculum, we suspected the pathology as crystal deposition disease. Based on polarized light microscopy, which revealed monocle or triclinic intracellular crystals with a positive birefringence, the patient was diagnosed with pseudogout of the lumbar spine. Nonsteroidal anti-inflammatory drugs (NSAIDs) were administered by intravenous drip injection for 3 days, and local and systemic inflammatory signs, as well as neurological deficits, dramatically improved. Conclusions We encountered the rare case of an acute attack of pseudogout with the wide lesion in the lumbar spondylolytic spondylolisthesis. Multiple culture of the effusion provided a definitive diagnosis, which allowed for appropriate, minimally invasive treatment for 8 weeks of NSAID administration that provided the satisfactory recovery from the symptoms.
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Trauma Induced Calcium Pyrophosphate Deposition Disease of the Lumbar Spine. Case Rep Rheumatol 2020; 2020:3218350. [PMID: 32095306 PMCID: PMC7035534 DOI: 10.1155/2020/3218350] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/20/2019] [Indexed: 02/07/2023] Open
Abstract
Inflammatory arthritis, such as pseudogout or otherwise referred to as calcium pyrophosphate (CPP) crystal arthritis or calcium pyrophosphate deposition (CPPD) disease, is characterized by the deposition of crystal formation and deposition in large joints. CPPD is known to affect the elderly population and commonly manifests as inflammation of knees, hips, and shoulders. CPPD disease involving the spine has been infrequently encountered in practice and rarely described in the literature. Here, we describe a case of an 80-year-old female with no known history of inflammatory arthritis who presented with left lower extremity weakness and fall, initially thought to have discitis, later confirming CPPD of the spine through biopsy and ultimately resolution of symptoms with anti-inflammatory agents. Although consisting of different clinical presentations, two other case reports have described CPPD of the spine with similar radiographic findings, to this author's knowledge. With the radiologic similarities, this unique case serves to raise awareness in the medical community and possibly place pseudogout of the spine on the differential list when such cases are encountered. As a result, patients can be initiated on benign anti-inflammatory agents, avoiding invasive testing and unnecessary antibiotic exposure.
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Singla A, Ryan A, Bennett DL, Streit JA, Mau B, Rozek M, Hitchon PW. Non-infectious thoracic discitis: A diagnostic and management dilemma. A report of two cases with review of the literature. Clin Neurol Neurosurg 2020; 190:105648. [PMID: 31931336 DOI: 10.1016/j.clineuro.2019.105648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 12/21/2019] [Indexed: 12/27/2022]
Abstract
Discitis/ Osteomyelitis is an inflammatory process involving an intervertebral disc and the adjacent vertebral bodies. Infection is the most common cause of discitis, which is often spontaneous and hematogenous in origin. However, many noninfectious processes affecting the spine such as pseudarthrosis in ankylosing spondylitis, amyloidosis, destructive spondyloarthropathy of hemodialysis, Modic changes type 1, neuropathic arthropathy, calcium pyrophosphate dehydrate (CPPD) spondyloarthropathy and gout can mimic infectious discitis/ osteomyelitis. To determine whether a particular patient's spinal process is due to an infectious versus non-infectious cause can be challenging. Although clinical findings and laboratory studies including erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) can be helpful in the diagnosis of bacterial discitis/osteomyelitis due to their high sensitivity; however, their specificity is low. Moreover, both the infectious and non-infectious discitis can appear quite similar on the imaging studies. We present two cases of thoracic discitis with adjacent vertebral osteomyelitis of probable non-infectious etiology. Both were managed with instrumented fusion for stabilization. We also discuss a range of noninfectious causes of discitis/spondylitis and their radiological features which can help differentiate from infectious processes.
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Affiliation(s)
- Amit Singla
- Department of Neurosurgery, Rutgers University, Newark, NJ, USA.
| | - Allison Ryan
- Department of Neurosurgery, Covenant Medical Center, Waterloo, Iowa, USA
| | - D Lee Bennett
- Department of Radiology, Musculoskeletal Radiology Section, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa, USA
| | - Judy A Streit
- Department of Internal Medicine - Infectious Diseases, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa, USA
| | - Brianna Mau
- Department of Neurosurgery, Covenant Medical Center, Waterloo, Iowa, USA
| | - Marek Rozek
- Department of Neurosurgery, Covenant Medical Center, Waterloo, Iowa, USA
| | - Patrick W Hitchon
- Department of Neurosurgery, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa, USA
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Knitza J, Kleyer A, Schett G, Manger B. [Chondrocalcinosis: idiopathic or manifestation of rare metabolic diseases?]. DER ORTHOPADE 2019; 48:949-956. [PMID: 31515589 DOI: 10.1007/s00132-019-03805-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Calcification in hyaline and fibrocartilage is caused by the deposition of calcium pyrophosphate dehydrate, commonly referred to as chondrocalcinosis. Clinically, this can lead to arthritis symptoms similar to a gout attack -"pseudogout". Nonetheless, also chronic or asymptomatic disease courses are possible. The prevalence of chondrocalcinosis increases with age. The diagnostic workup of degenerative joint disease, therefore, often reveals calcifications of articular cartilage as harmless incidental findings. However, particularly in patients younger than 60 years of age, chondrocalcinosis can be the symptom of an underlying metabolic disease. This review article highlights these rare diseases and presents unusual manifestations of chondrocalcinosis.
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Affiliation(s)
- J Knitza
- Medizinische Klinik 3 - Rheumatologie und Immunologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Deutschland.
| | - A Kleyer
- Medizinische Klinik 3 - Rheumatologie und Immunologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Deutschland
| | - G Schett
- Medizinische Klinik 3 - Rheumatologie und Immunologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Deutschland
| | - B Manger
- Medizinische Klinik 3 - Rheumatologie und Immunologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Deutschland
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Cheng CW, Nguyen QT, Zhou H. Tophaceous gout of the cervical and thoracic spine with concomitant epidural infection. AME Case Rep 2018; 2:35. [PMID: 30264031 DOI: 10.21037/acr.2018.07.01] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 06/07/2018] [Indexed: 12/16/2022]
Abstract
Tophaceous gout of the spine is an underappreciated source of back pain in patients with or without neurological decline. It has been reported to occur in the cervical, thoracic and lumbar spine. Rarely, does it occur at more than one region of the spine. Advanced imaging with magnetic resonance imaging and computed tomography are usually not helpful in differentiating between infection, malignancy and gout. Clinician should have a high suspicion of spinal gout in patients with history of gout who presents with renal insufficiency, presence of peripheral tophi on exam, with elevated serum uric acid and creatinine levels, erythrocyte sedimentation rate and C-reactive protein. Here we present a case of a 23-year-old male with history of gout and chronic renal disease with progressive weakness in his lower extremities with new urinary incontinence who was found to have spinal gout with epidural infection of both the cervical and thoracic spine. Our patient was successfully managed with surgical decompression followed by medical treatment with antibiotics and steroids.
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Affiliation(s)
- Christina W Cheng
- Department of Orthopaedics and Sports Medicine, Harborview Medical Center, Seattle, Washington, USA
| | - Quynh T Nguyen
- Department of Orthopaedics and Sports Medicine, Harborview Medical Center, Seattle, Washington, USA.,Department of Radiology, Harborview Medical Center, Seattle, Washington, USA
| | - Haitao Zhou
- Department of Orthopaedics and Sports Medicine, Harborview Medical Center, Seattle, Washington, USA
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When Calcium Pyrophosphate Deposition Disease Masquerades as Spinal Infection. J Clin Rheumatol 2018; 25:e118-e122. [PMID: 29667941 DOI: 10.1097/rhu.0000000000000727] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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