Can pseudogout (calcium pyrophosphate deposition disease) cause fever in elderly individuals?

Pseudogout Can Cause Fever in Elderly Persons

Yes, pseudogout (calcium pyrophosphate deposition disease) can cause fever in elderly individuals and should be considered as a potential cause of fever, especially when accompanied by joint pain or inflammation. 1

Understanding Fever in the Elderly

Fever in elderly patients has different diagnostic thresholds compared to younger adults:

• A single oral temperature ≥100°F (37.8°C)
• Repeated oral temperatures ≥99°F (37.2°C) or rectal temperatures ≥99.5°F (37.5°C)
• An increase in temperature of ≥2°F (≥1.1°C) over baseline temperature 1, 2

It's important to note that elderly patients may not mount the same febrile response as younger adults, and approximately 20-30% of elderly patients with serious infections may not present with fever 3.

Pseudogout and Fever Presentation

Pseudogout, defined as recurrent acute arthritis due to calcium pyrophosphate dihydrate crystal deposition, is a relatively common arthritic disorder in the elderly 4. When it causes fever, it typically presents with:

• Acute joint inflammation (most commonly knees, wrists, ankles, or elbows)
• Oligoarticular or polyarticular involvement (seen in about half of cases) 4
• Systemic inflammatory response that can include fever
• Radiographic evidence of chondrocalcinosis in most cases

Diagnostic Approach for Fever in Elderly with Suspected Pseudogout

When evaluating an elderly patient with fever who might have pseudogout:

1. Assess for joint symptoms:

   • Look for acute joint pain, swelling, redness, or warmth
   • Note that pseudogout can affect multiple joints simultaneously 4, 5

2. Consider precipitating factors:

   • Recent trauma, surgery, or infection can trigger pseudogout attacks 4
   • Chronic conditions like renal failure may increase risk 6, 5

3. Diagnostic testing:

   • Joint aspiration with identification of calcium pyrophosphate crystals under compensated polarized light microscopy is definitive 6
   • X-rays to look for chondrocalcinosis (linear stippled calcification in cartilage)
   • Complete blood count to assess for leukocytosis

Important Clinical Considerations

1. Differential diagnosis: When an elderly person presents with fever:

   • Infection remains the most common cause (25-30% of fever of unknown origin cases) 7
   • Multisystem diseases including temporal arteritis account for about 31% 7
   • Malignancies account for approximately 12% 7
   • Pseudogout should be considered, especially with joint symptoms

2. Atypical presentations: In elderly patients, pseudogout may present atypically:

   • More diffuse calcification patterns on imaging 6
   • Involvement of unusual joints like the elbow 6
   • May be mistaken for other forms of arthritis or infection

3. Associated conditions: Consider screening for:

   • Hyperparathyroidism
   • Hemochromatosis
   • Chronic renal failure 6, 5

Clinical Pitfalls to Avoid

1. Missing the diagnosis: Don't attribute fever in elderly patients solely to common infections without considering crystal arthropathies like pseudogout, especially when joint symptoms are present.

2. Overreliance on temperature thresholds: Remember that elderly patients may have significant infections or inflammatory conditions with only modest temperature elevations 1, 3.

3. Failure to aspirate affected joints: Joint aspiration with crystal analysis is essential for definitive diagnosis of pseudogout 6.

4. Overlooking associated metabolic conditions: Pseudogout can be a clue to underlying metabolic disorders like hyperparathyroidism or hemochromatosis 4.

By maintaining a high index of suspicion for pseudogout in elderly patients with fever and joint symptoms, clinicians can make an accurate diagnosis and provide appropriate treatment to improve outcomes and quality of life.