Ultrasound is a valuable diagnostic tool in assessing the following indications. This case illustrates an unusual acute cppd attack that mimicked an aortic dissection. Calcium pyrophosphate deposition, or pseudogout is almost identical to gout, causing attacks of pain and swelling in one or more joints. Gout, however, is caused by a different type of crystal. A rheumatologist certified in musculoskeletal ultrasound rt. Ultrasound of the shoulder in patients with gout and calcium pyrophosphate deposition disease. Usually just one joint is affected at any one time.
Codes to now portable, pointofcare ultrasound sonosite. New insights into cppd page 4 of 6 the rheumatologist. Pseudogout calcium pyrophosphate deposition symptoms. Ultrasound in the diagnosis of calcium pyrophosphate dihydrate deposition disease. Ultrasound has a high diagnostic performance for cppd.
Sonography is useful in evaluating the patellofemoral joint, including the trochlear cartilage, which is often difficult to image adequately on conventional. Oct 10, 2018 calcium pyrophosphate deposition, or pseudogout is almost identical to gout, causing attacks of pain and swelling in one or more joints. For example, basic calcium phosphate crystals cause acute calcific tendinitis and the milwaukee shoulder syndrome. Rheumatoid arthritis and pseudorheumatoid arthritis in. Clinical, radiographic and pathologic abnormalities in calcium pyrophosphate dihydrate deposition disease cppd pseudogout are outlined in an investigation of 85 patients with definite or probable disease and available cadaveric and human surgical material. Identification of calcium pyrophosphate deposition disease cppd by ultrasound. Calcium pyrophosphate dihydrate deposition disease. They conclude that ultrasound detects chondrocalcinosis with. Calcium pyrophosphate dihydrate deposition disease cppd is the third most. Buildup of calcium phosphate in the ankle joints has been found in about 50% of the general population, and may be associated with osteoarthritis another common cause of chondrocalcinosis is calcium pyrophosphate dihydrate. Musculoskeletal ultrasound was the first available method to evaluate and recognize diagnosis corroborating images suggestive for cppd disease to biological data hypercalcemia and hyperparathyroidism in finding the predisposing condition, the parathyroid adenoma. More significantly, calcium pyrophosphate crystals are related to a variety of articular manifestations known as calcium pyrophosphate deposition cppd arthritis.
Images in all 26 patients revealed multiple hyperechoic densities consistent with the us appearance of calcium pyrophosphate dihydrate cppd vs. Association with type 2 odontoid fractures in nine patients1. Calcium pyrophosphate dihydrate cppd crystal deposition disease is an umbrella term encompassing all instances of calcium pyrophosphate dihydrate cpp crystal precipitation in connective tissues seen in asymptomatic patients or associated with several clinical syndromes. Shoulder pain is the second most common joint problem presenting to doctors. Clinical, radiographic and pathologic abnormalities in. To investigate by high frequency ultrasonography the appearance of calcium pyrophosphate dihydrate cppd calcifications, in the most commonly affected sites in cppd disease, and the relationship between ultrasonographic cppd deposits and the presence of cppd crystals in synovial fluid. Indeed, the composite location of the different local structures and the complex anatomy makes the. Joint effusion posterior shoulder acoustic window for effusion g h. It occurs when calcium pyrophosphate crystals sit in the joint and surrounding tissues and cause symptoms like gout. For many years, the diagnosis of cppd has been based on the mccarty criteria 3, which includes the presence of typical crystal deposits at conventional radiology cr and synovial fluid analysis. Over time, joints may degenerate, or break down, resulting in longterm disability. Acute cpp crystal arthritis pseudogout symptoms, causes.
Calcium pyrophosphate dihydrate cppd crystal deposition disease, also known as pseudogout and pyrophosphate arthropathy, is a rheumatologic disease which is thought to be secondary to abnormal accumulation of calcium pyrophosphate dihydrate crystals within joint soft tissues. Calcium pyrophosphate deposition cppd disease, commonly called pseudogout, is a painful form of arthritis that comes on suddenly. Calcium pyrophosphate deposition arthritis foundation. Musculoskeletal ultrasound diagnosis in calcium pyrophosphate. Some people develop damage to the joint, causing a type of longterm arthritis. Ultrasonography ultrasound examination of affected joints is another imaging method that is increasingly being used to establish or confirm the diagnosis of cppd disease or to guide synovial fluid aspiration a joint tap to obtain material for synovial fluid analysis. The knee is the joint most commonly affected by this condition, but people can also get acute cpp crystal arthritis in the wrist, shoulder, ankle and occasionally other joints. Imaging of calcium pyrophosphate deposition disease ncbi. Chondrocalcinosis or cartilage calcification is calcification accumulation of calcium salts in hyaline andor fibrocartilage.
Ultrasound ultrasound us uses sound waves to produce images that can be used to evaluate a variety of musculoskeletal disorders. Yet, in cppd, a different type of crystal, called calcium pyrophosphate, triggers the reaction. In cppd, calcium pyrophosphate crystals form in the blood and settle in joint cartilage. Ultrasound of the shoulder medical ultrasonography. As with us in general, musculoskeletal us is highly operatordependent, and proper training and experience are required to perform consistent, high quality evaluations.
There was 100% interreader agreement of the us images, encompassing 7 anatomic sites shoulder, elbow, wrist, hand, knee, ankle, and foot. Imaging of calcium pyrophosphate deposition disease. Soft tissue calcification can be caused by secondary tumoural calcinosis from renal. Pdf calcium pyrophosphate dihydrate cppd crystal deposition disease.
Gout and calcium pyrophosphate deposition disease online medical reference covering definition through treatment. Pdf clinical and ultrasound findings in patients with calcium. Gout, gouty arthritis, tophi, ultrasonography, diagnostic imaging. Cppd is a type of arthritis that, as the old name of pseudogout suggests, can cause symptoms similar to gout. Indications for ultrasound omeract 7 msk us definitions r. Guidelines for musculoskeletal ultrasound in rheumatology. As with us in general, musculoskeletal us is highly operatordependent, and proper training and experience are required to. Click to open a pdf showing a broad classification of tendon tears. Ultrasonography in chondrocalcinosis sciencedirect. Imaging in gout and other crystalrelated european society of. Anteroposterior radiograph of the right shoulder shows a calcific tendinopathy of the supraspinatus. In the patients, the joint cartilage was significantly. Identification of calcium pyrophosphate deposition disease.
Therefore, the presence of cppd crystals in synovial fluid and radiographic changes more in keeping with oa favour a diagnosis of pseudora, while elevated titres of anticyclic citrullinated peptide anticcp antibodies and the presence of bony erosions either on ultrasound or plain film radiographic imaging indicate a diagnosis of classical ra. A total of 262 patients with cppd disease and 335 controls from 4 original articles and 4 abstracts were included in the metaanalysis. The shoulder is an excellent region for the use of ultrasoundguided diagnosis and intervention due to its high injury prevalence and the superficial nature of commonly injured structures peng p. Ideally the examiner holds the probe in their left hand for a right shoulder with the right arm free to control the buttons on the machine and likewise holding the probe in their right hand for scanning a left shoulder with the examiners left arm free to. Anatomy four muscles attach as tendons onto the proximal humerus and make up the rotator cuff. Ultrasound of the shoulder in patients with gout and calcium pyrophosphate. Diagnosis of calcium pyrophosphate dihydrate crystal deposition. These symptoms tend to last from several days to two weeks. There is little research into the prevalence of symptomatic calcium pyrophosphate deposition cppd disease. Information on calcium pyrophosphate deposition cppd for patients and caregivers.
Ultrasound is known to be more sensitive than radiography, however, when acoustic shadowing is present, it. Iames unlimited cme plan is now the internets best value for online cme in. You must also have the capability to display and print pdf files in order to view and print out your certificate. Three ultrasonographic patterns of cppd calcification were identified and 11 patients. In a 1995 study, ultrasonography features found at the knee using a 7. Rheumatoid arthritis and pseudorheumatoid arthritis in calcium pyrophosphate dihydrate crystal deposition disease.
Oct 11, 2001 the radiographic diagnosis of calcium pyrophosphate dihydrate cppd deposition disease is usually made by observing calcifications in the articular cartilage of large joints or, in the knee, noting calcification in the menisci. Calcium pyrophosphate deposition disease cppd is caused by the. Chondrocalcinosis, which is calcification of the articular cartilage, most often caused by cppd, is estimated to affect 5% of the general population, and prevalence increases with age. Three ultrasonographic patterns of cppd calcification were identified and 11. By opting to use ultrasound as a first choice for shoulder imaging, i have the advantage of knowing the status of their rotator cuff, biceps tendon and other soft tissue anatomy at the time of their visit. Ultrasound is an essential investigation in shoulder examination and diagnosis. Diagnostic accuracy of ultrasound, xrays and synovial fluid in the diagnosis of calcium pyrophosphate dihydrate deposition disease. Registration must be completed to access these videos, but no fee is required. Calcium pyrophosphate deposition cppd is a type of arthritis. Authored by feyrouz alashkar of the cleveland clinic.
Crystalinduced arthropathies are a group of disorders that involve deposition of crystals into joints and soft tissues, resulting in articular and periarticular inflammation and injury. Diagnosis of gout by ultrasound rheumatology oxford academic. Calcium pyrophosphate dihydrate deposition disease cppd is the third most common inflammatory arthritis 1 and its prevalence grows with ageing 2. Additional ultrasound resources instructional videos demonstrating proper performance of the ultrasound examination of the shoulder and related pathology can be found at the website of the american medical society for sports medicine. Throughout his ed stay, his pain was refractory to medication, and he developed a new fever, prompting a targeted shoulder ultrasound. Panero, do a lthough ultrasound has been around for many years, the technology is underutilized. The radiographic diagnosis of calcium pyrophosphate dihydrate cppd deposition disease is usually made by observing calcifications in the articular cartilage of large joints or, in the knee, noting calcification in the menisci. Untreated calcium pyrophosphate deposition cppd may lead to severe, painful attacks or chronic longterm pain and inflammation. Milwaukee shoulder refers to a destructive shoulder arthropathy due to deposition of hydroxyapatite crystals, and identification of these crystals in synovial fluid is the cornerstone of diagnosis. Radiological identification and analysis of soft tissue. Major advances in cppd diagnostics include formal recognition by eular of the utility of highresolution ultrasound, now a standard tool for gout diagnosis. Shoulder pain and limited range of motion are very common complaints in the clinical practice and the shoulder is a joint site that particularly lends itself to ultrasound us assessment. Cppd arthritis is very common and its incidence increases with age. Cppd deposits and the presence of cppd crystals in synovial fluid.
To investigate the clinical presentation of bakers cyst in patients with calcium pyrophosphate dehydrate cppd calcifications of the knee, the most commonly affected site in cppd deposition disease, with the use of highresolution musculoskeletal ultrasound mus. Ultrasound is essentially used for the rotator cuff complex of the shoulder. Indeed, the composite location of the different local structures and the complex anatomy makes the use of us appropriate for the evalua. Your cme certificate is stored in your account and is available at any time. Calcium pyrophosphate deposition cppd disease bpj 55. Codes to now a guide to ultrasound of the shoulder, part 1. Ultrasound cppd in peripheral joints appears as punctuate pattern. Musculoskeletal ultrasound was able to detect effusion, hyperechoic crystals within the cartilage and fibrocartilage, inside tendons, suggestive for cppd disease and to guide fluid aspiration as well as in sustaining a rapid diagnosis corroborating images suggestive for cppd disease to biological data hypercalcemia and hyperparathyroidism.
Diagnosis of calcium pyrophosphate dihydrate crystal. Ultrasonographic diagnosis of articular chondrocalcinosis. Crystal arthropathies are a group of joint disorders due to deposition of crystals in and around joints which lead to joint destruction and soft tissue masses. Diagnostic value of ultrasound in calcium pyrophosphate deposition disease. Ultrasound energy is absorbed mostly in tissues with high collagen content bone, periosteum, cartilage, ligaments, capsules, tendons, fascia, scar tissue and tissue interface i.
Ultrasound in the diagnosis of calcium pyrophosphate dihydrate. Calcium pyrophosphate dihydrate crystal deposition disease. Calcium pyrophosphate deposition cppd is a type of. Shoulder ian beggs, uk stefano bianchi, switzerland angel bueno, spain michel cohen, france michel courtpayen, denmark andrew grainger, uk franz kainberger, austria andrea klauser, austria carlo martinoli, italy eugene mcnally, uk philip j. Eightyeight patients with a crystal proven diagnosis of gout or calcium pyrophosphate dihydrate cppd disease attending the inpatient and the outpatient clinics of four italian rheumatology.
Calcium pyrophosphate dihydrate cppd crystal deposition disease is extremely versatile. Does this patient have calcium pyrophosphate dihydrate crystal deposition disease. Diagnostic value of ultrasound in calcium pyrophosphate deposition. Ultrasound in the diagnosis of calcium pyrophosphate. Cppd can be found in all articular tissues, including hyaline cartilage and fibrocartilage. Calcium pyrophosphate dihydrate deposition disease assoc prof craig hacking and assoc prof frank gaillard et al. The shoulder is an excellent region for the use of ultrasound guided diagnosis and intervention due to its high injury prevalence and the superficial nature of commonly injured structures peng p. The joint cartilage is normally seen on ultrasound scans as two hyperechoic lines separated by a uniform echofree zone.
Cppd used to be called pseudogout because it is easily mistaken for gout. More and more clinicians recognise the advantages of offering patients a onestop diagnostic service. Ge medical systems, milwaukee, wi on a ge logic 3 ultrasound machine. Ultrasound at high intensity near bony areas can be detrimental to the periosteum because of high energy accumulation and heating effect on. Calcium pyrophosphate dihydrate disease cppd, also known as pyrophosphate arthropathy or pseudogout, is defined by the cooccurrence of arthritis with evidence of cppd deposition within the articular cartilage. Calcium pyrophosphate dihydrate crystal deposition in and around the atlantoaxial joint. Gout crystal arthropathy calcification imaging radiography ultrasound. Ultrasound diagnosis of chondrocalcinosis in the knee. It has been used primarily by the radiologists and obstetriciansgynecologists.
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