Newly developed pseudogout arthritis after therapy with MAGE-A4 directed TCR T cells responded to treatment with tocilizumab.

With durable cancer responses, genetically modified cell therapies are being implemented in various cancers. However, these immune effector cell therapies can cause toxicities, including cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). Pseudogout arthritis is an inflammatory arthritis induced by deposition of calcium pyrophosphate dihydrate crystals. Here, we report a case of pseudogout arthritis in a patient treated with MAGE-A4 directed T cell receptor T cells, for fallopian tube cancer. The patient developed CRS and ICANS 7 days after infusion of the T cells. Concurrently, the patient newly developed sudden onset of left knee arthritis. Synovial fluid analyses revealed the presence of calcium pyrophosphate dihydrate crystal. Notably, the pseudogout arthritis was resolved with tocilizumab, which was administered for the treatment of CRS and ICANS. Immunoprofiling of the synovial fluid showed that the proportion of inflammatory interleukin 17 (IL-17)-producing CD4+ T (Th17) cells and amount of IL-6 were notably increased, suggesting a potential role of Th17 cells in pseudogout arthritis after T-cell therapy. To the best of our knowledge, this is the first reported case of pseudogout arthritis after cell therapy. Clinicians, especially hematologists, oncologists and rheumatologists, should be aware that pseudogout arthritis can be associated with CRS/ICANS.

A case of acute calcium pyrophosphate arthritis in two rare sites of involvement: The cervical facet and atlantoaxial joint.

Calcium pyrophosphate dihydrate deposition (CPPD) disease, also known as pseudogout, in which crystals are deposited in the joints and/or soft tissues, leads to a variety of articular and periarticular disorders. Herein we report a 67-year-old female patient with neck pain who was diagnosed as CPPD disease of both the atlantoaxial joint and right C4-C5 facet joint with radiological findings. The combined use of computed tomography and magnetic resonance imaging can be helpful in establishing a diagnosis and providing the correct treatment.

Crowned dens syndrome, yet another rheumatic disease imposter.

OBJECTIVE: Crowned dens syndrome (CDS) is defined as acute cervical or occipital pain due to a local inflammatory reaction related to calcifications in the ligaments surrounding the odontoid process. Virtually, all previous descriptions of CDS have related to calcium pyrophosphate dehydrate (CPPD) arthropathy. METHODS: We prospectively identified a total of twenty-four consecutive inpatients with Crowned dens syndrome from January 2016 to December 2017 in our institution. RESULTS: All patients (age range 54 to 87 years, 67% females) presented with acute onset pain in the upper neck and/or occiput accompanied with extreme neck stiffness. Most patients (79%) had elevated inflammatory markers. Four patients underwent temporal artery biopsy, which was negative for arteritis in all cases, and one was subjected to lumbar puncture, which was non-contributory. Seventeen patients (71%) had known rheumatic disease on presentation: 10 patients had the diagnosis of calcium pyrophosphate dehydrate arthropathy, 3 patients had ankylosing spondylitis, 2 patients had rheumatoid arthritis, 1 patient had Behcet's disease, and 1 suffered from Familial Mediterranean Fever. In 4 more patients, crowned dens syndrome was the presenting symptom of calcium pyrophosphate dehydrate disease. All patients were treated with glucocorticoids as 0.5 mg/kg prednisone plus colchicine 0.5 mg bid resulting in dramatic improvement in both clinical (head/neck pain alleviated and cervical spinal mobility regained) and laboratory measures. CONCLUSIONS: Crowned dens syndrome should be considered, and craniocervical junction imaged in the context of acute cervical or occipital pain with stiffness and elevated inflammation markers not only in patients previously diagnosed with calcium pyrophosphate dehydrate arthropathy but also in diverse clinical settings.Key Points• This report highlights that crowned dens syndrome should be considered in various clinical setting besides calcium pyrophosphate dehydrate (CPPD) arthropathy.• Vigilance to this syndrome allows rapid treatment and may spare the patient unnecessary invasive procedures (i.e., temporal artery biopsy or lumbar puncture).

Crystal arthritides - gout and calcium pyrophosphate arthritis : Part 1: Epidemiology and pathophysiology.

Gout and calcium pyrophosphate deposition disease (CPPD, pseudogout) are still the most frequent inflammatory arthritides in multimorbid elderly patients. Gout and CPPD are different diseases and based on different pathophysiological principles. Gout is closely associated with the metabolic syndrome and is an independent risk factor for cardiovascular mortality. The prevalence of asymptomatic hyperuricemia is estimated to be 10-20% of adults in industrial nations and prevalence is strongly associated with age. More than 7% of persons aged over 65 years suffer from clinically manifest gout. The underlying pathophysiological principle is an imbalance between the formation and elimination of uric acid. The degradation of the purine bases adenine and guanosine to uric acid is catalysed by xanthine oxidase and genetic polymorphisms and mutations play an important role in absorption and excretion processes. Furthermore, carrier proteins, such as URAT-1 or OAT-4 also have an influence on these processes. An imbalance of the physiological processes results in the solubility product being exceeded, which in consequence leads to crystallization of urate. This induces a cascade of massive inflammatory reactions at the molecular and cellular level with the activation of cytokines. The inflammatory process can be stopped by neutrophil extracellular traps (NETs) that modulate aggregation and degradation of chemokines and cytokines and partitioning of crystallized urate against immune cells. Calcium pyrophosphate dehydrate (CPP) crystals are formed in the cartilage and CPP deposition can be found in 30% of people aged over 80 years. Inorganic pyrophosphate (PPi) is synthesized in chondrocytes and plays an important part in the formation of calcium pyrophosphate crystals. The degradation is catalyzed by inorganic pyrophosphatases. If there is dysregulation of this homeostasis more PPi is produced, which ultimately contributes to the formation of the CPP crystals.

Crystalline arthropathy and bone health.

PURPOSE OF REVIEW: The purpose of this review is to provide insight on the proposed association between crystal arthritis and bone health. Crystal arthritis is the most common type of inflammatory arthritis, and fractures contribute to significant morbidity and mortality, therefore, the relationship between the two is of clinical importance. RECENT FINDINGS: There have been variable findings regarding hyperuricemia, low bone density and risk of fracture. A recent systematic review and meta-analysis of available literature showed a correlation between increased serum uric acid and lower risk of fracture. Less is known about calcium pyrophosphate deposition disease and bone health, although two large studies have suggested an association with osteopenia. SUMMARY: A systematic review and meta-analysis of available data suggest a correlation between increased serum uric acid and lower risk of fracture. Findings support an association between bone health and crystal arthritis which warrants further study and may have implications for how we treat gout.

Nonrheumatoid Arthritis of the Hand.

Arthropathy of the hand is commonly encountered. Contributing factors such as aging, trauma, and systemic illness all may have a role in the evolution of this pathology. Besides rheumatoid arthritis, other diseases affect the small joints of the hand. A review of nonrheumatoid hand arthropathies is beneficial for clinicians to recognize these problems.

Monoarticular Arthritis.

Monoarticular arthritis is inflammation characterized by joint pain, swelling, and sometimes periarticular erythema. Although chronic causes are seen, the onset is often acute. An infected joint can quickly lead to permanent damage, making it a medical emergency. However, acute gout presenting as monoarticular arthritis is often so uncomfortable it requires urgent attention. Monoarticular crystalline arthritis is common and a septic joint is a medical emergency so it is no surprise that these diagnoses come to mind with complaint of inflammation in 1 joint. However, there are many causes of monoarticular arthritis that clinicians must consider.

Mechanobiological implications of articular cartilage crystals.

PURPOSE OF REVIEW: Calcium crystals exist in both pathological and normal articular cartilage. The prevalence of these crystals dramatically increases with age, and crystals are typically found in osteoarthritic cartilage and synovial fluid. Relatively few studies have examined the effects of crystals on cartilage biomechanics or chondrocyte mechanotransduction. The purpose of this review is to describe how crystals could influence cartilage biomechanics and mechanotransduction in osteoarthritis. RECENT FINDINGS: Crystals are found in both loaded and unloaded regions of articular cartilage. Exogenous crystals, in combination with joint motion, result in substantial joint inflammation. Articular cartilage vesicles promote crystal formation, and these vesicles are found near the periphery of chondrocytes. Crystallographic studies report monoclinic symmetry for synthetic crystals, suggesting that crystals will have a large stiffness compared with the cartilage extracellular matrix, the pericellular matrix, or the chondrocyte. This stiffness imbalance may cause crystal-induced dysregulation of chondrocyte mechanotransduction promoting both aging and osteoarthritis chondrocyte phenotypes. SUMMARY: Because of their high stiffness compared with cartilage matrix, crystals likely alter chondrocyte mechanotransduction, and high concentrations of crystals within cartilage may alter macroscale biomechanics. Future studies should focus on understanding the mechanical properties of joint crystals and developing methods to understand how crystals affect chondrocyte mechanotransduction.

Dual-Energy Computed Tomography Demonstrating Destructive Calcium Pyrophosphate Deposition Disease of the Distal Radioulnar Joint Mimicking Tophaceous Gout.

Calcium pyrophosphate dihydrate deposition (CPPD) disease is a common etiology of crystalline arthropathy; however, it can manifest in multiple patterns such as acute calcium pyrophosphate (CPP) crystal arthritis, osteoarthritis with CPPD, and chronic CPP crystal inflammatory arthritis. Tumoral or tophaceous-like CPPD is a rare manifestation that is occasionally mistaken for gouty tophus or a soft tissue malignancy. Dual-energy computed tomography (DECT) is a new imaging modality currently utilized in assessing monosodium urate crystal deposition; however, its value in CPPD is uncertain. We describe a case using DECT to diagnose tumoral CPPD mimicking tophaceous gout versus recurrence of a previous synovial sarcoma. The imaging findings on DECT prevented unnecessary surgery to assess for possible malignancy, allowing for the prompt diagnosis of tumoral CPPD. Further studies should be performed to determine the role of DECT in assessing for crystalline deposition disease other than gout.

Methotrexate: should it still be considered for chronic calcium pyrophosphate crystal disease?

Chronic calcium pyrophosphate crystal arthritis is a clinical consequence of the formation and deposition of these crystals in joints and can result in persistent arthritis. Curative treatment would require the removal of crystals from joints and tissues, but to date all agents tested have proven ineffective. Management of the inflammatory manifestations of chronic calcium pyrophosphate disease includes glucocorticoids, non-steroidal anti-inflammatory drugs, or colchicine, and responses are usually satisfactory. However, in some patients, the response to these agents is poor or they are contraindicated. Methotrexate had been reported as a promising option in small case series; however, in a recent issue of Arthritis Research & Therapy, a clinical trial failed to confirm the anticipated benefits. Here, we discuss some issues that might have influenced the results of the study, before deciding to abandon methotrexate as a therapeutic option for patients with chronic calcium pyrophosphate arthritis.

Destructive pseudo-neuroarthropathy associated with calcium pyrophosphate deposition.

BACKGROUND: Calcium pyrophosphate deposition (CPPD) disease is a metabolic disorder characterized by soft tissue calcific deposits formed primarily in articular cartilage. What can result is a crystal-induced arthropathy often referred to as pseudogout, which is variable in both presentation and severity. A particularly destructive and deforming arthritis is an uncommon but well-recognized subtype of this disease. Radiologically resembling the neuroarthropathy described by Charcot, a pattern of joint fragmentation and structural collapse occurs in the absence of peripheral neuropathy. This pseudo-neuroarthropathy is rarely reported in the foot and ankle. METHODS: A total of 15 cases of pseudo-neuroarthropathy involving some previously unreported joints within the foot and ankle are described in this case series of 9 patients. RESULTS: All patients presented with disease involving multiple joints. Clinical deformity was apparent in each case, and extensive joint destruction was seen on plain radiographs. In 6 patients, histopathological CPPD disease was confirmed on tissue biopsy of the affected joints. In the remaining 3 patients a clinical diagnosis was made on the basis of the classic appearance of pseudo-neuroarthropathy in the foot, with additional recognized features of CPPD. Operative management with deformity correction using joint arthrodesis produced satisfactory clinical and radiological results. CONCLUSIONS: In the absence of peripheral neuropathy and systemic disease, the pseudo-neuroarthropathy of CPPD should be considered when a progressively deforming and destructive arthritis is seen in the foot and ankle. LEVEL OF EVIDENCE: Level IV, case series.