[Acute monoarthritis in a third level hospital]. / Estudio de los pacientes con monoartritis aguda en un hospital de tercer nivel.

INTRODUCTION: Acute monoarthritis (AM) represents a relevant cause of morbidity that requires prompt medical care. The study of synovial fluid becomes relevant to allow a rapid diagnostic approach. The main objective of the study was to determine the frequency and clinical-analytical characteristics of episodes of AM and acute bursitis evaluated in a hospital during a period of 6 years. METHODS: Cross-sectional retrospective analytical study in a hospital at Córdoba, Argentina. All episodes of acute monoarthritis and bursitis that occurred in patients aged 18 years or older between 2012 and 2017 were included. AM in pregnant women and chronic monoarthritis were excluded. RESULTS: One hundred and eighty episodes of AM and 12 of acute bursitis were included. Among the AM, 120 (66.7%) occurred in male patients and the average age was 62.1±16.9 years. The main cause of AM was septic, identifying 70 (36%) cases, followed by microcrystalline AM identify 54 (28%) cases, which corresponded to gout and calcium pyrophosphate dihydrate (CPPD) with 27 (14%) cases each one. Monosodium urate crystals were identified in 26 (14.3%) patients, CPPD in 28 (15.6%) and cholesterol in 1 (0.6%). DISCUSSION: The main cause of AM was septic arthritis, followed by microcrystalline AM (gout and secondary to CPPD). The main affected joint was the knee, followed by the shoulder. Synovial fluid analysis was a key element when making the differential diagnosis between the different causes of acute monoarthritis and bursitis.

Introducción: La monoartritis aguda (MA) representa una causa relevante de morbilidad que requiere de atención médica oportuna: El estudio del líquido sinovial constituye un elemento clave para su diagnóstico. El objetivo del estudio fue determinar la frecuencia y características clínicas-analíticas de los episodios de MA y bursitis agudas valoradas en un hospital durante un período de 6 años. Métodos: Estudio analítico retrospectivo de corte transversal en un hospital de Córdoba, Argentina. Se identificaron todos los episodios de monoartritis y bursitis agudas que ocurrieron en pacientes de =18 años entre 2012 y 2017. Se excluyeron los cuadros de MA en embarazadas y las monoartritis crónicas. Resultados: Se incluyeron 180 episodios de MA y 12 de bursitis aguda. Entre las MA, 120 (66.7%) ocurrieron en hombres, la edad promedio fue 62.1±16.9 años. La principal causa de MA fue séptica, identificándose 70 (36%) casos, seguida la secundaria a microcristales con 54 episodios (28%) que correspondieron 27 (14%) a MA por gota y 27 (14%) a MA por depósitos de pirofosfato de calcio dihidratado (CPPD). Se identificaron cristales de urato monosódico en 26 (14.3%) pacientes, CPPD en 28 (15.6%) y de colesterol en 1 (0.6%). Discusión: La principal causa de MA fue séptica, seguida de la secundaria a microcristales (gota y secundaria a CPPD). La principal articulación afectada fue la rodilla, seguida del hombro. El análisis del líquido sinovial fue un elemento clave a la hora de poder realizar el diagnóstico diferencial entre las distintas causas de monoartritis aguda y bursitis.

Knee effusion: ultrasound as a useful tool for the detection of calcium pyrophosphate crystals.

The objective of this study was to evaluate the sensitivity and specificity of ultrasound (US) and conventional radiography (CR) for the detection of calcium pyrophosphate (CPP) crystals in patients with knee effusion. Consecutive patients ≥50 years old with knee effusion were included. All patients underwent arthrocentesis with aspiration of synovial fluid (SF) and subsequent analysis of CPP crystals using plain light and polarizing light microscopy. US and CR of the involved knee were performed immediately after arthrocentesis. CR results were read by an experienced rheumatologist, searching for chondrocalcinosis. US examinations were carried out by an experienced rheumatologist blinded to all clinical and imaging data. The following US abnormal findings were considered indicative of CPP crystals deposition (CPPD): (1) hyperechoic bands within the femoral hyaline cartilage layer, and (2) hyperechoic sparkling spots in meniscal fibrocartilage. A total of 75 knees were evaluated in the same number of patients. Analysis of SF revealed CPP crystals in 15 out of 75 (20 %) knees: all (10) patients with previous diagnosis of CPPD, 3 patients with previous diagnosis of primary knee osteoarthritis (OA) and 2 patients without previous definitive diagnosis of a rheumatic condition. Using SF analysis as reference method, sensitivity and specificity for US findings was 60 and 96.7 %, respectively, while CR showed a sensitivity of 40 % and a specificity of 83.3 %. US results showed high specificity with acceptable sensitivity to detect CPP crystals in patients with knee effusion. Compared with CR, US results had better specificity and sensitivity. US may be used in daily rheumatologic practice when CPPD is suspected.

Myelopathy due to calcification of the cervical ligamenta flava: a report of two cases in West Indian patients.

Two cases of cervical myelopathy due to calcification of the ligamenta flava (CLF) are described for the first time in black patients from the French West Indies. A pre-operative CT scan differentiated the diagnosis from one of ossification of the ligamenta flava. Microanalysis on the operatively excised specimen in one patient revealed a mixture of calcium pyrophosphate dihydrate crystals and hydroxypatite crystals. Poor outcome in one patient contrasting with excellent recovery in the other one, who had undergone posterior decompressive laminectomy, emphasizes the importance of surgery in the management of CLF.

Crise de pseudogota como complicaçäo após paratiroidectomia no hiperparatiroidismo primário / Pseudogout crisis as a post parathyroidectomy complications in the primary hyperparathyroidism

A pseudogota é um quadro agudo ou sub-agudo de artrite associada à presença de cristais de diidrato de pirofosfato de cálcio (DHPC) no espaço sinovial. Relaciona-se ao hiperparatiroidismo primário (HPP), principalmente quando da reduçao rápida da calcemia que ocorre após a paratiroidectomia, Relatamos o caso de uma paciente de 71 anos de idade internada em nosso serviço por apresentar dores ósseas e articulares difusas com duraçao de dois anos. Os exames laboratoriais mostraram cálcio total de 11,4 mg/dl (normal: 8,5 a 10,5 mg/dl), cálcio ionizado de 1,36 mmol/L (normal: 1,14 a 1,29 mmol/L) e paratormônio intacto de 279 pg/ml (normal: 10-70 pg/ml), tendo sido feito diagnóstico de HPP. As radiografias simples evidenciaram condrocalcinose em joelhos, cotovelos e punhos. Submetida a paratiroidectomia, que revelou hiperplasia das paratiróides, evoluiu com hipocalcemia no oitavo dia pós-operatório (cálcio ionizado de O,9 mmol/l) e no décimo-primeiro dia apresentou artrite em tornozelo esquerdo. A punçao articular mostrou líquido sinovial com numerosos cristais sugerindo pseudogota. Na evoluçao, houve melhora articular concomitante à normalizaçao da ca;cemia e ao uso de anti-inflamatório nao hormonai. Um mês depois foi observado recidiva da artrite em punho e cotovelo esquerdos concomitante a novo surto de hipocalcemia. Em resumo, a pseudogota é uma complicaçao importante em pacientes com HPP submetidos à paratiroidectomia. Na opiniao dos autores, por estar associada à hipocalcemia, a pseudogota pode ser prevenida mediante a suplementaçao precoce de cálcio e vitamina D no pós-operatório imediato.