Would a course of steroids remove evidence of pseudogout on an X-ray?

Steroids Do Not Remove Evidence of Pseudogout on X-ray

A course of steroids will not remove the radiographic evidence of pseudogout (calcium pyrophosphate dihydrate disease) on X-ray. 1 Steroids treat the inflammatory symptoms of pseudogout but do not affect the characteristic calcifications visible on imaging.

Understanding Pseudogout Radiographic Findings

Pseudogout is characterized by specific radiographic findings that persist regardless of anti-inflammatory treatment:

• Chondrocalcinosis: Calcification of cartilage, especially in fibrocartilage of wrists, knees, and symphysis pubis 1
• Calcifications: In tendons, ligaments, and joint capsules 1
• Characteristic distribution: Radiographically visible changes typically involve the radiocarpal, metacarpophalangeal, atlantoaxial, and patellofemoral joints 1

X-ray is the primary imaging modality for pseudogout diagnosis, with the American College of Radiology giving it the highest appropriateness rating (9/9) for suspected calcium pyrophosphate dihydrate disease 1.

Why Steroids Don't Affect Radiographic Findings

Steroids work by:

• Reducing inflammation and pain during acute attacks
• Suppressing the inflammatory response to calcium pyrophosphate crystals
• Decreasing joint swelling and improving symptoms

However, steroids cannot:

• Dissolve or remove calcium pyrophosphate crystal deposits
• Alter the structural calcifications visible on X-ray
• Change the underlying pathophysiology of crystal deposition

Diagnostic Approach to Pseudogout

The gold standard for diagnosis remains synovial fluid analysis showing:

• Weakly positive birefringent rhomboid-shaped crystals under polarized light microscopy 2
• Crystals appear blue when parallel to the slow axis of the red compensator 2
• Crystals appear yellow when perpendicular to the slow axis 2

Imaging Findings That Persist Despite Treatment

1. X-ray findings (rated 9/9 for appropriateness by ACR 1):

   • Chondrocalcinosis in fibrocartilage and hyaline cartilage
   • Calcification of tendons, ligaments, and joint capsules
   • Characteristic arthropathy pattern

2. Ultrasound findings (rated 5/9 for appropriateness 1):

   • "Icing" of cartilage (double contour sign) with 83% sensitivity and 76% specificity 1
   • Echogenic synovial hypertrophy

3. CT findings (rated 5/9 for appropriateness 1):

   • Clear visualization of chondrocalcinosis and calcifications
   • Better detection of subtle calcifications than X-ray

Treatment of Pseudogout

While steroids don't remove radiographic evidence, they are effective for symptom management:

• NSAIDs: First-line if no contraindications 3
• Corticosteroids: Effective as systemic or intra-articular treatment, especially when NSAIDs are contraindicated 3, 4
  • Intramuscular triamcinolone acetonide (60mg) has shown good clinical response in pseudogout 4
• Colchicine: Effective for recurring pseudogout attacks 3
• ACTH: Alternative for patients with multiple medical problems 5
• Advanced therapies: In resistant cases, medications like anakinra (IL-1 receptor antagonist) have shown efficacy 6

Clinical Pearls and Pitfalls

• Pitfall: Assuming normal X-rays after steroid treatment means pseudogout is not present
• Pitfall: Confusing resolution of acute symptoms with resolution of underlying crystal deposition
• Pearl: Radiographic evidence of pseudogout persists even after successful treatment of acute attacks
• Pearl: Pseudogout can be mistaken for infection after joint procedures, as seen in cases following unicondylar knee arthroplasty 7

In summary, while steroids effectively treat the inflammatory symptoms of pseudogout, the radiographic evidence of calcium pyrophosphate crystal deposition remains unchanged on X-ray following steroid treatment.