Will a burst of steroids (corticosteroids) remove evidence of pseudogout from an X-ray of the elbow?

Effect of Corticosteroids on Pseudogout X-ray Evidence in the Elbow

A burst of corticosteroids will not remove the radiographic evidence of pseudogout (calcium pyrophosphate deposition disease) from an X-ray of the elbow, as the calcifications seen on X-rays represent structural deposits that remain visible despite anti-inflammatory treatment.

Radiographic Features of Pseudogout

Pseudogout is characterized by calcium pyrophosphate dihydrate (CPPD) crystal deposition in joints, which appears on X-rays as:

• Punctate and linear radiodense areas in fibrocartilage and hyaline cartilage 1
• Chondrocalcinosis (calcification in cartilage)
• Triangular fibrocartilage complex chondrocalcinosis in wrists 2

X-rays are the most appropriate initial imaging modality for evaluating chronic elbow pain and show characteristic findings of pseudogout 1. The American College of Radiology rates X-ray as the highest priority imaging study (rating 9/9) for suspected calcium pyrophosphate dihydrate disease 1.

Effect of Corticosteroids on Pseudogout

Corticosteroids work by:

• Reducing inflammation associated with crystal-induced arthritis 1
• Decreasing pain and swelling during acute attacks 3
• Providing symptomatic relief 4

However, corticosteroids do not:

• Dissolve or remove the calcium pyrophosphate crystal deposits visible on X-rays
• Alter the structural changes or calcifications that have already formed
• Prevent progression of joint destruction 4

Treatment Approach for Pseudogout

For acute pseudogout attacks:

1. First-line options:

   • NSAIDs (if not contraindicated)
   • Intra-articular corticosteroid injections
   • Systemic corticosteroids (when NSAIDs are contraindicated) 4, 3

2. Alternative options:

   • Intramuscular triamcinolone acetonide (60mg) has shown good clinical response in pseudogout, especially when NSAIDs are contraindicated 3
   • Colchicine can be effective for recurring pseudogout 4
   • Anakinra (IL-1 receptor antagonist) has been used successfully in resistant cases 5

Important Clinical Considerations

• Pseudogout flares can occur after parathyroidectomy due to rapid changes in calcium levels 2

• Most cases are idiopathic, but secondary causes should be ruled out:

  • Hyperparathyroidism
  • Hemochromatosis
  • Hypomagnesemia
  • Hypophosphatemia 4

• Diagnosis is confirmed by:

  1. Synovial fluid analysis showing positively birefringent CPPD crystals under compensated polarized light microscopy
  2. X-rays showing characteristic calcifications 4

Conclusion

While corticosteroids effectively treat the inflammatory symptoms of pseudogout and can lead to clinical improvement, they do not remove the calcium pyrophosphate crystal deposits that are visible on X-rays. The radiographic evidence of pseudogout will persist despite successful treatment of the acute inflammatory phase with corticosteroids.