A case report of basic calcium phosphate deposition disease mimicking septic arthritis.

We report a case of a 53-year-old man who presented with a diagnostic dilemma mimicking septic arthritis. It is important to consider the diagnosis of calcific peri-arthritis clinically and recognize the hallmarks on radiograph and magnetic resonance imaging as this disease process resolves completely with conservative management like in our patient, and does not require operative intervention.

Role of Newman's classification in predicting outcomes in patients with crystal arthritis.

PURPOSE: The aim of the study was to evaluate the utility of Newman's classification in predicting outcomes in patients presenting with crystal arthritis. METHODS: Between January and December 2009, all patients who presented to our institution with acute crystal arthritis and were investigated with microbiological assessment of their synovial fluid were included in the study. Patients were divided into two groups depending on the fulfilment of Newman's criteria for culture-negative septic arthritis. Group 1 included patients that fulfilled Newman's B criteria. Group 2 included patients that fulfilled Newman's C criteria. A database looking at the demographics, mode of presentation, investigations, treatment and outcomes was then established and the results compared between the two groups. RESULTS: A total of 58 patients were identified (group 1: n = 13; group 2: n = 45). The average age was 71 years (range 33-96). The joint most commonly involved was the knee followed by the wrist. Clinical findings at presentation were comparable in both groups; however, WBC and C-reactive protein (CRP) were more likely to be raised in group 1. Although most patients in group 1 were treated with antibiotics (62%) there was still a higher rate of morbidity, greater use of supportive therapy and a longer hospital stay (22.3 days, SD 17.4) in comparison with group 2, where most patients were treated by observation only (76%, mean hospital stay 3.5 days, SD ± 4.4). The difference in length of hospital stay was statistically significant (p < 0.0001). CONCLUSIONS: Newman's criteria are a good indicator for prognosis in patients with crystal arthritis. However, the presence of crystals in an acutely inflamed joint does not exclude the need for supportive therapy and long hospital stay even in the absence of positive synovial fluid culture.

Does the nature of deposited basic calcium phosphate crystals determine clinical course in calcific periarthritis of the shoulder?

OBJECTIVE: Two typical clinical courses of calcific periarthritis in the shoulder are known: acute, with severe inflammation, and chronic, in the form of impingement syndrome with secondary subacromial bursitis. It remains unclear what factors determine these clinical courses. Our objectives were to clarify whether the calcified deposits that occur in both acute and chronic cases are composed of carbonate apatite; and to compare the Ca:P molar ratio in the 2 forms and to determine if there was any correlation in this respect with the intensity of inflammation induced by basic calcium phosphate crystals. METHODS: Ten samples were aspirated from 10 women (ages 42-65 yrs) with acute inflammation. The average time from first attack to aspiration was 2.3 days. A further 10 samples were operatively removed from 10 women (ages 35-58 yrs) with refractory chronic subacromial bursitis, among whom an average of 7.8 months had passed since the onset of symptoms. All samples were analyzed by x-ray diffraction, Fourier transform infrared spectroscopy, and Raman spectroscopy, and Ca:P molar ratios were measured by x-ray fluorescence spectrometry. RESULTS: Calcified deposits from both acute and chronic cases were identified as carbonate apatite, and not hydroxyapatite, octacalcium phosphate, tricalcium phosphate, or dicalcium phosphate dihydrate. The average Ca:P molar ratio of calcified deposits was calculated as 1.71 +/- 0.16 in acute cases and 1.71 +/- 0.16 in chronic cases (statistically nonsignificant). CONCLUSION: Deposits around the shoulder in both acute and chronic calcific periarthritis are composed of carbonate apatite, Ca:P molar ratios being almost identical in the 2 forms. The results suggest that some factor other than the composition of the crystalline deposits may determine clinical course in calcific periarthritis of the shoulder.

Recovery process of arthritis induced by 6-sulfanilamidoindazole (6SAI) in rats.

6-Sulfanilamidoindazole (6SAI) is known to induce not only an acute arthritis but also serositis and arteritis which resemble those induced by some vasodilators in rats. In this study, the recovery process of ankle lesions was examined histopathologically for up to 12 weeks of recovery period in rats bearing arthritis induced by administration of 6SAI (500 mg/kg) for 2 weeks. At 2 weeks of 6SAI-treatment, exudative synovitis and exudative/edematous periarthritis with marked formation of granulation tissues and periosteal reactive bone formation were noted in the ankles, but no remarkable neutrophil infiltration was detected in those lesions. The ankle swelling induced by 6SAI diminished by 4 weeks of recovery period, and the elevated plasma fibrinogen levels were normalized by 2 weeks of recovery period. Although fibrosis and newly-formed periosteal bone were still observed after 2 weeks of recovery period, no inflammatory lesion was detected at that point. At 4 or 12 weeks of recovery periods, the ankles showed an almost normal appearance. These results indicate that 6SAI-induced arthritis is reversible in nature and does not develop into chronic phase.

Analysis of calcium deposits in calcific periarthritis.

OBJECTIVE: To determine if hydroxyapatite (HAP), octacalcuim phosphate (OCP), or tricalcium phosphate (TCP) can be found in the calcium deposits in calcific periarthritis. METHODS: Thirty-six specimens from 34 patients who had acute inflammation and roentgenographically recognized calcification in soft tissue were analyzed. Twenty-three patients with calcific tendinitis in the shoulder and 11 with calcific periarthritis at other sites were included. We prepared 2 kinds of samples from each specimen; a dried sample (washed and dried calcific deposit), and a sample heated to 1,000 degrees C. All were analyzed by X-ray diffraction, Raman spectroscopy, infrared absorption spectroscopy, and X-ray fluorescence spectrometry for calcium and phosphorus molar ratio. Synthetic HAP was used as the control in each analysis. RESULTS: The X-ray diffraction patterns of all dried samples were similar to those of HAP and carbonate apatite. We found no diffraction patterns of OCP or TCP. However, an OH- group at 3570cm(-1) was observed with Raman spectroscopy for samples heated to 1,000 degrees C and synthetic HAP, but not for the dried samples. Infrared absorption spectroscopy also confirmed an OH- group for samples heated to 1,000 degrees C and synthetic HAP, and confirmed that dried samples contained carbonate. CONCLUSION: Calcium deposits are composed of carbonate apatite. HAP, OCP, and TCP were not identified in any deposits.

[Analysis of deposits in calcific periarthritis].

Analysis was conducted on calcific deposits from 5 patients with calcific periarthritis. These calcific deposits were dried, immersed in hydrazine, or heated to 1000 degrees C for 1 hour, to prepare 3 kinds of samples. The samples were classified as dried samples, hydrazine-deproteinated samples, or as heated samples. All samples were analyzed by X-ray diffraction (XRD). Fourier transform infrared spectroscopy (FTIR), Raman spectroscopy (Raman), and by electron probe microanalysis (EPMA). Although the XRD patterns of the dried samples and of the deproteinated samples were similar to that of hydroxyapatite (HAp), it was still unclear whether or not the calcific deposits were HAp. FTIR then revealed that the dried samples contained carbonate. Raman showed that the dried samples and the deproteinated samples do not have an OH-group. The dried samples were then heated to 1000 degrees C for one hour and analyzed by all 4 methods. The heated samples were found to be HAp. From these results, the calcific deposits from the 5 patients with calcific periarthritis were found to be carbonate apatite: Ca10-x-y/2 (PO4)6-x (CO3) x (OH) 2-y (CO3)y/2.nH2O.

Acute calcific periarthritis of the fingers.

Two cases of acute calcific periarthritis of the fingers are described and some controversial clinical aspects of the syndrome discussed.

Pathology from hydroxyapatite deposits in periarticular tissues. First conclusions on etiopathogenesis.

Biopsies of periarticular tissues from patients with episodes of chronic periarthritis were examinated by histological, ultrastructural and chemico-crystallographic methods. In all samples the mineralogical observations at the optical microscope, showed aggregates of microcrystalline incrustations, whose ultrastructural morphology has been characterized by SEM. The histological observations showed necrosis of collagen fibres and microcrystallization process in cavities and in metaplastic fibrocartilage. The HA deposits in the periarticular tissues, in the next stage of the process, are surrounded and demolished by macrophages and multinucleated giant cells. At the same time granulation tissue carries out the repair process, that begins with the formation of thin parallel collagen fibers interposed with many fibroblasts and numerous small vessels.

Acute calcific periarthritis in scleroderma.

Three patients with limited cutaneous scleroderma (CREST syndrome) and acute calcific periarthritis are presented. "Chalky" bursal effusion in one patient demonstrated masses of calcium hydroxyapatite crystals. In contrast to idiopathic acute calcific periarthritis, resorption of periarticular calcifications after resolution of acute attacks occurs both less frequently and incompletely in scleroderma associated acute calcific periarthritis.

Periarthritis associated with basic calcium phosphate crystal deposition and low levels of serum alkaline phosphatase--report of three cases from one family.

Three siblings, 2 women and one man, from an Iranian-Jewish family with low serum levels of alkaline phosphatase (liver fraction) and symptomatic calcific periarthritis of multiple joints are described. Both parents and 2 additional siblings had normal serum alkaline phosphatase levels and no joint symptoms. The disease in the proposita, a 49-year-old woman, showed 3 unusual features: (1) no rise in acute phase serum proteins despite severe attacks of periarthritis; (2) refractoriness to treatment; (3) pure octacalcium phosphate found in a deposit obtained by biopsy.

Hydroxyapatite deposition disease presenting as calcific periarthritis in a 14-year-old girl.

We report a case of hydroxyapatite deposition disease presenting as acute periarthritis in a 14-year-old girl with typical radiological features and clinical course. We also review the clinical and laboratory features to increase awareness of this entity.

Hydroxyapatite deposition disease.

Hydroxyapatite crystals are a common cause of periarticular disease, but recent studies have shown that they may also be deposited intra-articularly, either as a primary phenomenon or secondary to another disease. A continuum of abnormalities from monoarticular periarthritis to polyarticular disease and finally joint destruction may occur.

[Generalized periarthritis calcarea (generalized hydroxyapatite disease)]. / Die Periarthritis calcarea generalisata (General isierte Hydroxyapatikrankheit).

The condition of generalized periarthritis calcarea (hydroxyapatite deposition disease) is characterised by multiple periarticular calcification which can be localised around practically any joint and also in proximity to the spine. This calcification consists of hydroxyapatite crystals which are responsible for the episodes of acute, subacute or chronic periarticular or articular inflammation so typical of the condition. Because of this one can classify periarthritis calcarea along with gout and chondrocalcinosis in the group of crystal deposition diseases. The actual cause of the calcification remains unknown but it is probable that, along with hereditary factors, disturbances in metabolism play an important role. The diagnosis of generalised periarthritis is made from the characteristic X-ray picture in conjunction with the clinical findings and, on occasion, the demonstration of hydroxyapatite crystals in the affected tissues. In the differential diagnosis gout, chondrocalcinosis, various inflammatory rheumatic conditions and septic arthritis must be excluded and various calcification processes, particularly interstitial calcinosis and lipocal cinogranulomatosis, must also be considered. Since the etiology of the calcification remains unknown to specific treatment is available. Symptomatic treatment with colchicine is mostly inadequate which is why one often has recourse to the use of non-steroid anti-inflammatory drugs and corticosteroids.