Calcium Pyrophosphate Deposition Disease

by Carlo Raj, MD

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    00:02 Now that we've completed discussion of gout, which by definition is accumulation of what? Uric acid, here we'll take a look at what's known as calcium pyrophosphate deposition disease, or CPPD.

    00:15 You probably, commonly, in med school, and in your medical career, have come across a being pseudogout.

    00:20 I'll tell you why I want you to stay away from that, because you need to understand the actual pathology.

    00:27 So what is pseudogout? Well, pseudogout is not the accumulation of uric acid, so therefore, it's not gout.

    00:34 Pseudo, false.

    00:36 So what is it? It's accumulation of calcium.

    00:39 Focus on that. The full name is pyrophosphate, and the full name is calcium pyrophosphate deposition disease. CPPD. Correct? I told you to focus on calcium, why? Because presentation, especially when I give you the X-ray.

    00:55 I'm going to show you that there's going to be accumulation of calcium.

    00:58 What color does calcium appear on X-ray, opaque or loosened? Good, opaque.

    01:05 So, I'll show you something called chondrocalcinosis, And while we go through this, obviously, you're going to compare this with the gout, and you'll see just how simple it is.

    01:15 Pathogenesis. Deposition of the calcium pyrophosphate.

    01:19 Most commonly, where? Oh, I remember.

    01:22 In gout, where was the patient complaining of pain acute? In the big toe, right? Watching the football game, "Oh, it hurts. Stop it." Yeah. Well, this is the large joints that you're looking for here in pseudogout or CPPD.

    01:37 Next, I told you to focus on calcium.

    01:39 Chondral means cartilage.

    01:41 So in your joints, such as a knee and such, you're going to accumulate calcium, called chondrocalcinosis.

    01:48 It's the meniscus of the knee, maybe the pubic symphysis, and maybe the wrists. These are large joints.

    01:55 Now, there are associations Metabolic disorders such as hyperparathyroidism.

    02:03 What does that mean to you? Oh, increased calcium. There you go.

    02:07 Maybe hemochromatosis association. Keep that in mind.

    02:11 Could be hypothyroidism, hypomagnesemia, hypophosphatemia, and Wilson's disease, in other words copper.

    02:23 So there's important endocrine or electrolyte association that you want to keep in mind with deposition of CPPD.

    02:33 Signs and symptoms.

    02:34 Patient, typically, presents with acute symmetric arthritis.

    02:39 What was it in gout? It was one toe, podagra, asymmetric, monoarticular.

    02:45 These episodes are usually triggered by surgery, secondary to volume shifts, or even severe illness. Keep that in mind.

    02:53 And then, so we talked about how you could have pseudogout.

    02:58 In other words, the pain could be acute.

    03:01 It could be monoarticular.

    03:02 However, over a long period of time, let's say that the knee has been involved chronically.

    03:08 The presentation now kind of feels like a wear-and-tear type of pain.

    03:12 In other words, patient wakes up in the morning, feels a little bit of stiffness, but it's less than… less than 1 hour, maybe less than 30 minutes.

    03:19 Seems like osteoarthritis, but it's not.

    03:21 On X-ray, you find calcium accumulating on the cartilage.

    03:25 So therefore, in chronic… chronic CPPD, we then call this pseudo osteoarthritis.

    03:33 Or the pain might > 1 hour, and this may seem like rheumatoid arthritis.

    03:39 We call this pseudo rheumatoid arthritis.

    03:43 We haven't talked about rheumatoid arthritis yet.

    03:45 But this is all about depositing calcium pyrophosphate, acute, chronic.

    03:51 So we have pseudogout or we have pseudoosteoarthritis, or pseudorheumatoid arthritis.

    03:57 Keep that in mind for chronicity.

    04:00 The calcium pyrophosphate. Now, these are rhomboid.

    04:05 What shape were the gout crystals? Uric acid crystals? They were needle-like, weren't they? What was the type of light that we used to identify the needles of gout? Polarized light.

    04:17 Remind me again, in gout, those uric acid crystals, were they negative or positive birefringent? In gout, it was negative birefringent.

    04:28 If it was negative birefringent on polarized light, on parallel, was it yellow or blue? Yellow.

    04:36 Completely different when we talk about CPPD.

    04:39 Here, we slightly positively birefringent under polarized light.

    04:47 Now if we use parallel light for positive, guess what color that is? Blue.

    04:57 So, the biggest difference, therefore, on polarized light has been, with CPPD, on parallel light, it will be positively birefringent, and you know it because on parallel, it will be blue.

    05:09 If done parallel, it's yellow.

    05:11 That means it's negative.

    05:13 Number one differential, gout.

    05:15 Is that understood? If not, make sure you repeat what I just mentioned.

    05:19 Extremely important.

    05:21 Next, we'll talk about calcium.

    05:24 Once again, here, it is not uric acid, it's calcium.

    05:28 So this may then appear in soft tissue as well. What color is calcium? White on X-ray, in other words, opaque.

    05:37 Management of CPPD acutely would be that similar to gout acute, where we have anti-inflammatory drugs such as NSAIDs.

    05:48 You want to try to take care of the prophylaxis and prophylaxis usually will be with colchicine.

    05:54 Remember, associations that you could have, including hyperthyroidism, including hypothyroidism, hypomagnesemia, hemochromatosis, Wilson's and such, the associations take care of the underlying issue, as well.

    About the Lecture

    The lecture Calcium Pyrophosphate Deposition Disease by Carlo Raj, MD is from the course Introduction and Non-Autoimmune Arthritis. It contains the following chapters:

    • Introduction to Calcium Pyrophosphate Deposition Disease
    • Diagnosis of CPPD

    Included Quiz Questions

    1. Hyperthyroidism
    2. Hyperparathyroidism
    3. Hemochromatosis
    4. Hypothyroidism
    5. Hypophosphatasia
    1. Rhomboid shaped and weakly positively birefringent under polarized light
    2. Needle shaped and positively birefringent under polarized light
    3. Needle shaped and negatively birefringent under polarized light
    4. Rhomboid shaped and negatively birefringent under polarized light
    5. Envelope shaped and positively birefringent under polarized light
    1. Chondrocalcinosis
    2. Overhanging osteophytes
    3. Bone spurs
    4. Spondylosyndesis
    5. Subchondral sclerosis

    Author of lecture Calcium Pyrophosphate Deposition Disease

     Carlo Raj, MD

    Carlo Raj, MD

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