Calcific Periarthritis Research Articles

Molecular mechanisms of pain in crystal-induced arthritis.

Crystal-induced arthritis (CIA) is characterized by an intense inflammatory reaction triggered by the deposition of monosodium urate, calcium pyrophosphate, and basic calcium phosphate crystals in articular and periarticular tissues. Severe, acute pain constitutes the most important clinical symptom in patients affected by these diseases. Pain along with redness, warmness, swelling, and stiffness in the affected joint arises abruptly in gout and disappears when the acute phase of the attack resolves. While an acute joint attack caused by calcium pyrophosphate crystals can mimic a gout flare, basic calcium phosphate crystal arthritis gives rise to a series of clinical manifestations, the most severe of which are calcific periarthritis, mostly asymptomatic, and a highly destructive arthritis known as Milwaukee shoulder syndrome, which is characterized by painful articular attacks. Pain development in CIA is mediated by several inflammatory substances that are formed after cell injury by crystals. The most important of these molecules, which exert their effects through different receptor subtypes present in both peripheral sensory neurons and the spinal cord, are prostaglandins, bradykinin, cytokines (in particular, interleukin (IL)-1β), and substance P. The pharmacological treatment of pain in CIA is strictly associated with the treatment of acute phases and flares of the disease, during which crystals trigger the inflammatory response. According to international guidelines, colchicines, nonsteroidal anti-inflammatory drugs, and/or corticosteroids are first-line agents for the systemic treatment of acute CIA, while biologics, namely anti-IL-1β agents, should be used only in particularly refractory cases.

Calcium deposits in the hand and wrist.

Calcium, or calcific, deposition disease in the form of acute calcific periarthritis of the hand and wrist is an uncommon entity that may be confused with more common crystalline or inflammatory arthropathies as well as infection. It is important for the clinician to be aware of this disease process and to include it in the differential diagnosis of patients presenting with acutely painful, focal inflammation of the hand or wrist. Nonsurgical management is often sufficient; however, considering the self-limited nature of the disease, accurate diagnosis is essential to avoid unnecessary antibiotic or surgical treatment.

Arthroscopic Treatment of Symptomatic Calcific Periarthritis on the medial side of the knee after Posterior Cruciate Ligament Reconstruction : Case Report and Literature Review

Arthroscopic Treatment of Symptomatic Calcific Periarthritis on the medial side of the knee after Posterior Cruciate Ligament Reconstruction : Case Report and Literature Review

Clinical and Radiographic Findings in Adults With Persistent Hypophosphatasemia

A serum alkaline phosphatase value below the age-adjusted lower limits of normal (hypophosphatasemia) is uncommonly encountered in clinical practice. The electronic and paper medical records of 885,165 patients treated between 2002 and 2012 at a large, rural, multispecialty health clinic were interrogated to estimate the prevalence and characterize the clinical and radiographic findings of adults whose serum alkaline phosphatase was almost always low (persistent hypophosphatasemia). We hypothesized that some of these patients might harbor previously unrecognized hypophosphatasia, a rare, inherited condition of impaired mineralization of bones and teeth. Persistent hypophosphatasemia (serum alkaline phosphatase ≤ 30 IU/L) was found in 1 of 1544 adult patients. These adult patients had more crystalline arthritis, orthopedic surgery, chondrocalcinosis, calcific periarthritis, enthesopathy, and diffuse idiopathic skeletal hyperostosis than a general adult patient population. A gender effect was observed. The clinical and radiographic findings of adult patients with persistent hypophosphatasemia resemble those of the adult form of hypophosphatasia. Clinicians should take notice of persistent hypophosphatasemia, consider the diagnosis of hypophosphatasia, and be cautious when considering potent anti-remodeling therapy in these adults. This population warrants further evaluation.

Calcific periarthritis of the elbow presenting as acute tennis elbow

A 28-year-old woman presented with sudden acute lateral epicondylitis. There was no history of preceding trauma or repetitive use of the arm. Because of the acute onset and signs of acute inflammation, an X-ray was arranged. The X-ray showed a hyperdense calcified elongated globule distal to the lateral epicondyle. A diagnosis of calcific periarthritis (calcium apatite) of the elbow was made. Calcific periarthritis has rarely been reported as a cause of acute elbow pain.

Calcific Periarthritis as the Only Clinical Manifestation of Hypophosphatasia in Middle-Aged Sisters

Hypophosphatasia (HPP) is the inborn error of metabolism that features low serum alkaline phosphatase (ALP) activity caused by loss-of-function mutation(s) within the gene for the tissue nonspecific isoenzyme of ALP (TNSALP). In HPP, extracellular accumulation of inorganic pyrophosphate (PPi), a TNSALP substrate and inhibitor of mineralization, leads frequently to premature tooth loss and often to rickets or osteomalacia. In affected adults, the excess PPi sometimes also causes calcium pyrophosphate dihydrate (CPPD) deposition, PPi arthropathy, or pseudogout, or seemingly paradoxical deposition of hydroxyapatite crystals in ligaments or around joints when the condition is called calcific periarthritis (CP). We report three middle-aged sisters with CP as the only clinical manifestation of HPP. Each presented during early adult life with recurrent episodes of pain principally around the shoulders, elbows, wrists, hips, or Achilles tendon. Otherwise, they were in good health, including no history of unusual dental disease, fractures, or pseudofractures. Calcific deposits were identified in symptomatic areas principally by ultrasonographic assessment but also confirmed radiographically. All three sisters had low serum levels of total and bone-specific ALP, hyperphosphatemia, and increased serum concentrations of the TNSALP substrate pyridoxal 5'-phosphate together characteristic of HPP. Mutation analysis revealed that each carried a single unique 18-bp duplication within TNSALP (c.188_205dup18, p.Gly63_Thr68dup) as did two of their healthy sons and their mother, who was without signs of CPPD deposition or CP but had knee osteoarthritis. We find that CP can be the only complication of HPP in adults. Thus, multiple juxta-articular deposits of hydroxyapatite causing CP may be a useful sign of HPP, especially when the CP is familial.

SP0096 GOUT and other crystal diseases

Unlike other chronic arthropathies we have good understanding of gout pathogenesis and have effective treatment strategies to eliminate the pathogenic agent (urate crystals) to effect a “cure”. This is not...

Causation and management of calcific tendonitis and periarthritis

The purpose of this review is to update the reader on contemporary theory related to the cause of calcific periarthritis and provide the latest evidence associated with treating recalcitrant cases. Contemporary theory suggests calcific periarthritis is the result of a cellular-mediated process in which calcium is deposited and resorbed via a multiple phase process. Resorption is associated with an acute inflammatory response and is often the factor that prompts one to seek medical care. The majority of cases require nothing more than a combination of symptomatic care and benign neglect. A small percentage of cases require intervention to further stimulate deposit resorption. Moderate evidence exists for extracorporeal shock wave therapy in the treatment of chronic cases related to deposits about the shoulder. Numerous case studies support the use of NSAIDs as an effective intervention for retropharyngeal periarthritis. If conservative interventions fail, surgery appears to be a viable option for symptom relief associated with rotator cuff calcific deposits. Periarthritis is typically a symptom-limiting condition that resolves spontaneously. Numerous conservative treatment modalities each with varying levels of evidence exist for use in refractory cases. Future study is necessary to further refine the efficacy and parameters associated with available interventions.

Acute calcium deposits in the hand and wrist; comparison of acute calcium peritendinitis and acute calcium periarthritis

Acute calcium deposits are characterized by acute pain and a radiographic finding of amorphous calcification. A prospective, observational study was carried out on 30 consecutive patients undergoing conservative treatment for acute calcium deposits of the hand and wrist. Thirteen patients presented with acute calcific peritendinitis (Group A), and the other 17 with acute calcific periarthritis (Group B). All patients were followed for more than 12 months (mean 29 months). The average age at onset and recurrence rate of acute calcific peritendinitis were both significantly greater than for acute calcific periarthritis.

Calcific Periarthritis: More Than a Shoulder Problem

Calcific periarthritis, referring to a circumscribed juxta-articular deposit of minute non-birefringent mineral grains, is rarely the clinical diagnosis accompanying a pathologic specimen. Familiarity with the clinical, pathologic, and radiologic manifestations of calcific periarthritis, particularly when encountered adjacent to joints other than the shoulder, facilitates diagnosis and may obviate biopsy, avoid confusion with other entities, and speed appropriate treatment. Pathologic specimens that fulfilled the criteria for a diagnosis of calcific periarthritis were prospectively collected. Clinical history and radiologic studies were acquired and analyzed. Well-controlled special stains were employed on two specimens with a neutrophilic infiltrate that excluded fungal and bacterial agents, as corroborated by microbiologic cultures showing no growth. Over a five-year period, fifteen patients between the ages of thirty-one and eighty-eight years (mean age, fifty-nine years) presented to various local healthcare providers for treatment of juxta-articular swelling that was subsequently determined to be calcific periarthritis. In seven patients, deposits were alongside a toe joint; in five, alongside a finger joint; and in three, involving the shoulder. The majority of the patients were female (73%). No patient had a documented recurrence of calcific periarthritis in follow-up periods ranging from eighteen to eighty-seven months (average forty-five months). Of twelve histologically verified cases of calcific periarthritis adjacent to joints other than the shoulder, in only one patient (toe) was the preoperative clinical diagnosis accurate, which signals the need for greater awareness of this entity as a differential diagnostic option.

Adult hypophosphatasia with painful periarticular calcification treated with surgical resection

Hypophosphatasia is a rare inherited disorder characterized by a low serum alkaline phosphatase (ALP) activity and defective bone mineralization. Adult hypophosphatasia typically manifests in middle-age as a result of osteomalacia with recurrent stress fractures of the lower limb. However, considerable variation occurs in the clinical expression of hypophosphatasia, and no curative treatment has yet been established. We herein report a case of adult hypophosphatasia with painful calcific periarthritis, which showed improvement after surgical resection. A 32-year-old male was referred to our clinic complaining of pain in his elbows and knees. A painful subcutaneous mass was palpable on his right lateral epicondyle, where periarticular calcification was detected by plain radiography. The laboratory data showed a slight decrease in serum ALP activity and bone mineral density, and an elevation in the urinary phosphoethanolamine. Genomic DNA sequencing revealed an F310L mutation and a Y246H polymorphism in the tissue-nonspecific alkaline phosphatase gene, confirming the diagnosis of hypophosphatasia. The pain in the patient's right elbow was not responsive to nonsteroidal anti-inflammatory drugs, and triamcinolone diacetate was locally injected for treatment. His symptoms were ameliorated after the injection; however, they recurred in 3months, and he became refractory to additional steroid injection. Surgical debridement of the calcified lesion was performed, and his symptoms were successfully ameliorated after the surgery.

Acute calcific peri-arthritis of the hands: pseudogout presentation in five cases

AbstractBackgroundAcute peri-arthritis in the hands may simulate septic arthritis.ObjectivesRaising the awareness on this form of arthritis in emergency departments.Case reportFive patients having acute arthritis in hand joints with negative blood test results and radiographs showing peri-articular calcification.ConclusionThe series is a reminder to include acute calcific peri-arthritis in the differential diagnosis of acute arthritis of the hand joints.

Shoulder Manifestations of Diabetes Mellitus

The musculoskeletal system can be affected by diabetes in a number of ways. The shoulder is one of the frequently affected sites. One of the rheumatic conditions caused by diabetes is frozen shoulder (adhesive capsulitis), which is characterized by pain and severe limited active and passive range of motion of the glenohumeral joint, particularly external rotation. This disorder has a clinical diagnosis and the treatment is based on physiotherapy, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections and, in refractory cases, surgical resolution. As with adhesive capsulitis, calcific periarthritis of the shoulder causes pain and limited joint mobility, although usually it has a better prognosis than frozen shoulder. Reflex sympathetic dystrophy, also known as shoulder-hand syndrome, is a painful syndrome associated with vasomotor and sudomotor changes in the affected member. Diabetic amyotrophy usually affects the peripheral nerves of lower limbs. However, when symptoms involve the shoulder girdle, it must be considered in the differential diagnosis of shoulder painful conditions. Osteoarthritis is the most common rheumatic condition. There are many risk factors for shoulder osteoarthritis including age, genetics, sex, weight, joint infection, history of shoulder dislocation, and previous injury, in older age patients, diabetes is a risk factor for shoulder OA. Treatment options include acetaminophen, NSAIDs, short term opiate, glucosamine and chondroitin. Corticosteroid injections and/or injections of hyaluronans could also be considered. Patients with continued disabling pain that is not responsive to conservative measures may require surgical referral. The present review will focus on practice points of view about shoulder manifestations in patients with diabetes.

Can clodronate be effective in the treatment of disabling hydroxyapatite crystal-deposition disease? A report of two cases

Hydroxyapatite crystals are often deposited in the vicinity of joints, where they can cause a clinical periarthritis. Clodronate is a first-generation bisphosphonate that has the ability to reduce ectopic calcifications. Two women were affected by disabling calcific periarthritis of the shoulders lasting for years and resistant to any traditional drug (including glucocorticoids), infiltration and surgical treatment. We treated both patients with low-dose methylprednisolone added to intramuscular clodronate at the daily dose of 100mg administered for 20days every 3months for 5 cycles (18months). In both cases, the results were clinically evident within 1month, showing a significant reduction in pain and disability. After 18months, the result was furthermore radiologically evident in both cases with a great reduction in the size of calcifications. These improvements were still present at follow-up after 7 and 5years with complete functional recovery.

Acute calcific periarthritis of the hand and wrist: a series and review of the literature

This article presents three patients with acute calcific periarthritis (ACP) of the hand and wrist. ACP is an unusual, painful, monoarticular, periarticular inflammatory process associated with juxtaarticular deposits of amorphous calcium hydroxyapatite. ACP is a distinct clinical subset of hydroxyapatite deposition disease. ACP has a high rate of misdiagnosis because of its rare occurrence and its clinical resemblance to other entities. Clinical presentation may simulate infection, and the associated periarticular calcifications may be mistaken for gout, pseudogout, or other entities. One third of patients with ACP provide a history of antecedent trauma. Treatment is conservative. Patients typically will have a reduction in symptoms within 4-7 days after the acute onset of pain. Radiographically, the periarticular mineralization usually resolves or markedly decreases within 2-3 weeks, although on occasion, some calcifications may remain visible for months. Failure to recognize and correlate the typical clinical and radiographic presentation of this disease may lead to unnecessary diagnostic tests, invasive procedures, and inappropriate medication.

Rheumatological manifestations of diabetes mellitus - a review

The aim of this paper is to review literature on rheumatological manifestations of diabetes mellitus. An English language literature search using Medline and PubMed (1968 January to December 2003) was done to assess research / review articles on rheumatological manifestations of diabetes mellitus A variety of rheumatological conditions are strongly associated with diabetes mellitus including limited joint mobility, specific arthropathies of the hand (carpal tunnel syndrome, Dupytrens contracture, flexor tenosynovitis and diabetic sclerodactyly), shoulder (adhesive capsulitis-frozen shoulder, and calcific periarthritis) and spontaneous infarction of skeletal muscle. On the other hand, there are some conditions that are weakly associated with diabetes mellitus including osteoarthritis and chondrocalcinosis. The likely pathogenetic mechanisms, diagnosis and the management of these conditions are discussed. Poorly controlled and untreated diabetes mellitus of a long duration may be associated with some rheumatological conditions. The presence of these rheumatological conditions should prompt clinicians in screening the individual for diabetes mellitus.Keywords: diabetes mellitus, musclo-skeletal Nigerian Medical Practitioner Vol. 48(3) 2005: 77-83

Acute Calcific Periarthritis of the Hand

Acute Calcific Periarthritis of the Hand

Calcific tendinosis and periarthritis: classic magnetic resonance imaging appearance and associated findings.

Calcification within tendon and periarticular soft tissues with or without a history of pain is commonly encountered in the interpretation of musculoskeletal MR imaging (MRI) studies. This article presents a pictorial illustration of both the classic and atypical MR imaging (MRI) features of soft tissue calcifications in the musculoskeletal system. Familiarity with this topic can help to avoid pitfalls in imaging diagnosis.

A Case of Probable Hydroxyapatite Deposition Disease (HADD) of the Hip

We describe a patient with acute calcific periarthritis in an unusual site, the ilio-femoral ligament. The clinical findings in this patient resembled those of septic arthritis. T2*-weighted images with gradient field echo clearly showed foci of low signal intensity in this region, corresponding to the calcification shown on plain radiographs, and increased signal intensity around the foci, representing edema. These signal intensities were diagnostic of the disease.

Acute Calcific Periarthritis of Proximal Interphalangeal Joint in a Professional Golfer's Hand

This report describes a 22-yr-old professional golfer with acute calcific periarthritis of the proximal interphalangeal joint of the 4th finger. We considered that the major cause for this condition may be the repeated minor traumas to the affected site. Also, since this condition is self-limiting, a correct diagnosis is required to avoid unnecessary tests and surgery.