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Crystal Arthropathies

Crystal Arthropathies is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Precipitation of crystals in the synovium or synovial fluid causing acute or chronic symptoms in the articular space or adjoining tissues
  • Most common is monosodium urate (MU) crystals (gout); others include calcium pyrophosphate dihydrate (CPPD—pseudogout), calcium hydroxyapatite, and calcium oxalate crystals; lipid, plain calcium phosphate, and immunoglobulin crystals also described
  • Intra-articular crystals initiate an immune response and neutrophil phagocytosis which release inflammatory factors as the hallmark of crystalline arthropathies.
  • Joint aspiration is required for diagnosis in all but the most classic presentations of gout.
  • Uncontrolled disease can lead to chronic joint changes and disability and can herald underlying comorbid disease processes.
  • Most treatments are aimed at decreasing crystal-based inflammation.

Epidemiology

Incidence
  • Gout arthropathy 2 to 3/1,000 person years, blacks > white, men > women (1)
  • CPPD (pseudogout), hydroxyapatite, and calcium oxalate are less likely and generally confined to older patients.

Prevalence
  • Gout: increasing over time, from 2.7% to 3.7% (NHANES III)
  • Prevalence of other crystal arthropathy is not well defined.
  • Calcium oxalate is rare.

Etiology and Pathophysiology

  • High levels of crystal-forming molecules precipitate in synovium and synovial fluid.
  • An inflammatory response is induced, attracting neutrophils to the synovial tissues.
  • Subsequent phagocytosis of the crystals releases a cascade of additional inflammatory factors from neutrophils and monocytes.
  • Gout: Hyperuricemia is a prerequisite of MU crystals.
  • CPPD: believed to be from overproduction of pyrophosphate from chondrocytes
  • Hydroxyapatite is a normal part of bone metabolism, and crystallization is seen in associated tissue damage associated with elderly joints.
  • Calcium oxalate crystals form in patients with hyperoxalemia or with end-stage renal disease.

Genetics
  • Genetics play a role in hyperuricemia and familial CPPD disease.
  • Clinical application of genetic studies limited

Risk Factors

  • Age
  • Dehydration
  • Chronic renal disease
  • Underlying arthritic disease
  • Parathyroid disease
  • Calcium, phosphorus, or magnesium derangements

Commonly Associated Conditions

  • CPPD (also called chondrocalcinosis)
    • Mostly idiopathic
    • Hereditary CPPD
    • Hyperparathyroidism
    • Hemochromatosis
    • Hypophosphatasia
    • Hypomagnesemia
  • Hydroxyapatite
    • Tissue damage
    • Parathyroid, calcium, or phosphorus disorders
  • Calcium oxalate
    • Excessive ascorbic acid intake
    • Renal failure

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Citation

Stephens, Mark B., et al., editors. "Crystal Arthropathies." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816812/all/Crystal_Arthropathies.
Crystal Arthropathies. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816812/all/Crystal_Arthropathies. Accessed March 22, 2019.
Crystal Arthropathies. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816812/all/Crystal_Arthropathies
Crystal Arthropathies [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 March 22]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816812/all/Crystal_Arthropathies.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Crystal Arthropathies ID - 816812 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816812/all/Crystal_Arthropathies PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -