What is the diagnosis and treatment for a 60-year-old patient with chondrocalcinosis, also known as pseudogout, presenting with joint pain and swelling, and a history of hyperparathyroidism, hemochromatosis, or osteoarthritis?

Chondrocalcinosis (Pseudogout): Diagnosis and Management

Diagnosis

For a 60-year-old patient presenting with joint pain and swelling, plain radiographs should be obtained first to identify characteristic calcifications of fibrocartilage and hyaline cartilage, followed by joint aspiration with synovial fluid analysis to confirm calcium pyrophosphate (CPP) crystal deposition and exclude infection. 1, 2

Initial Imaging Approach

• Conventional radiography is the appropriate first-line imaging modality, demonstrating punctate and linear radiodense calcifications in fibrocartilage (menisci) and hyaline cartilage, particularly in the knee 3, 1, 4
• Obtain anteroposterior, lateral, and tangential patellar views to fully evaluate for chondrocalcinosis and associated arthropathy 1
• Radiographic chondrocalcinosis has 100% specificity for CPPD disease, though sensitivity is lower than ultrasound 3

Confirmatory Testing

• Joint aspiration with synovial fluid analysis is essential when effusion is present to identify positively birefringent CPP crystals under compensated polarized light microscopy and to exclude septic arthritis 1, 2, 4
• Aspiration can be performed under ultrasound or fluoroscopic guidance 1

Advanced Imaging (When Indicated)

• Ultrasound outperforms radiography for detecting chondrocalcinosis and can demonstrate the "double contour sign" and echogenic synovial hypertrophy 3, 1
• CT has diagnostic informativity nearly equal to conventional radiography and can identify calcification of tendons, ligaments, and joint capsules 3, 1
• MRI without contrast may be indicated when symptoms persist despite radiographic findings, to evaluate for synovitis, bone marrow lesions, or other soft tissue pathology 1

Metabolic Workup

Given the patient's history of hyperparathyroidism, hemochromatosis, or osteoarthritis, screening for metabolic conditions is critical, especially if the patient is under 60 years of age. 2, 4

• Primary hyperparathyroidism increases CPPD risk 3-fold (OR=3.03,95% CI 1.15 to 8.02) 3
• Hemochromatosis, hypomagnesemia, and hypophosphatemia can promote or cause chondrocalcinosis 4, 5
• Early-onset disease (before age 60) requires evaluation for hereditary hemochromatosis, hyperparathyroidism, and hypomagnesemia 3, 4, 5

Treatment Strategy

Asymptomatic Chondrocalcinosis

Asymptomatic radiographic chondrocalcinosis requires no treatment, as it is often an age-related finding in the normal population 3, 2

Acute CPP Crystal Arthritis (Pseudogout Attack)

For acute attacks, first-line treatment combines local measures (ice packs, rest, joint aspiration) with intra-articular glucocorticosteroid injection. 3, 2

Non-Pharmacological Measures

• Apply ice or cool packs to the affected joint 3, 2
• Temporary rest of the affected joint 3, 2
• Joint aspiration to remove inflammatory fluid 3, 2

Pharmacological Treatment

• Intra-articular long-acting glucocorticosteroid injection is highly effective for monoarticular or oligoarticular attacks 3, 2
• Oral NSAIDs with gastroprotective treatment (if gastrointestinal risk factors present) are effective systemic options 3, 2
• Low-dose oral colchicine (0.5 mg three to four times daily, with or without 1 mg loading dose) is an alternative to NSAIDs 3, 2
  • Traditional high-dose colchicine regimens (1 mg loading, then 0.5 mg every 2 hours) cause 100% incidence of side effects and should be avoided 3
  • Adjust colchicine dosing in renal impairment to avoid toxicity 2, 6

Prophylaxis for Recurrent Attacks

For patients with frequent recurrent acute attacks, prophylactic low-dose colchicine or NSAIDs should be initiated. 3, 2

• Low-dose oral colchicine for prophylaxis 3, 2, 7
• Low-dose oral NSAIDs with gastroprotective treatment if indicated 3, 2

Chronic CPPD Arthropathy

The management objectives and treatment options for osteoarthritis with CPPD are identical to those for osteoarthritis without CPPD. 3, 2

• Standard osteoarthritis management principles apply 3, 2
• No definitive treatment exists to prevent formation or enhance dissolution of CPP crystals 3

Treatment of Associated Metabolic Conditions

If hyperparathyroidism, hemochromatosis, or hypomagnesemia is identified, treat the underlying metabolic disorder according to disease-specific guidelines. 3, 2

• Whether treatment of comorbidity affects CPPD-associated arthritis outcome remains unclear 3

Critical Pitfalls and Caveats

Medication Safety in Elderly Patients

• NSAIDs and corticosteroids require cautious use in elderly patients due to increased risk of gastrointestinal bleeding, cardiovascular events, and renal toxicity 3, 2
• Consider gastroprotective agents (proton pump inhibitors) when prescribing NSAIDs 3, 2

Colchicine Dosing Adjustments

• In severe renal impairment (CrCl <30 mL/min), reduce colchicine starting dose to 0.3 mg/day 6
• For patients on dialysis, use 0.3 mg twice weekly for prophylaxis, or single 0.6 mg dose for acute treatment (not repeated more than once every two weeks) 6
• In hepatic impairment, monitor closely and consider dose reduction 6

Infection Exclusion

• Always perform joint aspiration with sterile technique when effusion is present to exclude septic arthritis, which can coexist with or mimic pseudogout 1, 2
• Infection is a common antecedent problem triggering pseudogout attacks 8

Drug Interactions with Colchicine

• Colchicine levels increase dramatically with CYP3A4 inhibitors (clarithromycin increases AUC by 281.5%, cyclosporine by 259%, ketoconazole by 212.2%, ritonavir by 296%) 6
• Dose reduction or avoidance is necessary when combining colchicine with strong CYP3A4 or P-glycoprotein inhibitors 6

Clinical Presentation Variability

• Oligoarticular and polyarticular episodes occur in approximately 50% of patients 8
• Antecedent triggers include infection, trauma, surgery, and vascular events 8
• One-third of patients develop pyrophosphate arthropathy, a progressive destructive form resembling accelerated osteoarthritis 8