Images in Clinical Rheumatology
Hydroxyapatite and Calcium Pyrophosphate Crystals Mimicking Gout in Systemic Sclerosis
Cristales de hidroxiapatita y pirofosfato de calcio imitando gota en una paciente con esclerosis sistémica
Lucio Ventura-Ríos
, Diana Ferrusquia-Toriz
Corresponding author
Laboratorio de Ultrasonido Musculoesquelético y Articular, Instituto Nacional de Rehabilitación «Luis Guillermo Ibarra Ibarra», Mexico City, Mexico
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(B) Abundant round clusters of calcium hydroxyapatite stained with alizarin. (C) A few extracellular rectangular calcium pyrophosphate crystals showing positive birefringence seen under polarized light microscopy.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The patient was a 61-year-old woman who presented with moderate pain and functional limitation of left knee that had begun 4 months earlier. She had a 2-year history of systemic sclerosis. Physical examination revealed that the knee was swollen and warm. Her erythrocyte sedimentation rate was 47<span class="elsevierStyleHsp" style=""></span>mm/h. Radiographies of the knees were normal. Ultrasound images of the knees with power Doppler at a moderate frequency demonstrated synovitis, a double contour sign over the femoral cartilage (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A) and calcification of the medial meniscus. Synovial fluid analysis by polarized light microscopy revealed abundant hydroxyapatite (HA) crystals (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B), and a few consisting of calcium pyrophosphate (CP) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). Hydroxyapatite crystals have been reported in hyaline cartilage or in the synovial fluid of patients with autoimmune diseases, such as scleroderma and pseudogout.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">1,2</span></a> We have found no previous accounts of the double contour sign over the cartilage associated with HA deposition similar to that described in gout. The typical radiographic findings in pseudogout include a thin band parallel to the bony cortex, but separated from it by the hypoechoic area corresponding to the cartilage.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> The association between the linear calcification of the cartilage or meniscus observed in pseudogout and HA crystals is unexpected.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> It could be that both HA and CP crystals contributed to the images observed. There is little information in the literature concerning the specific ultrasonographic characteristics of arthropathy related to HA. Thus, it is important to analyze the synovial fluid prior to establishing the definitive diagnosis.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical Disclosures</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Protection of human and animal subjects</span><p id="par0010" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Confidentiality of data</span><p id="par0015" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Right to privacy and informed consent</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of Interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:3 [ "identificador" => "sec0005" "titulo" => "Ethical Disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0020" "titulo" => "Right to privacy and informed consent" ] ] ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of Interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-02-08" "fechaAceptado" => "2016-04-03" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ventura-Ríos L, Ferrusquia-Toriz D. Cristales de hidroxiapatita y pirofosfato de calcio imitando gota en una paciente con esclerosis sistémica. Reumatol Clin. 2017;13:235–236.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 523 "Ancho" => 1800 "Tamanyo" => 113129 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Longitudinal view of femoral cartilage showing the double contour sign. (B) Abundant round clusters of calcium hydroxyapatite stained with alizarin. (C) A few extracellular rectangular calcium pyrophosphate crystals showing positive birefringence seen under polarized light microscopy.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hyaline cartilage involvement in patients with gout and calcium pyrophosphate deposition disease. An ultrasound study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "E. Filippucci" 1 => "E. Gutierrez" 2 => "D. Georgescu" 3 => "F. Salaffi" 4 => "W. 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Acciai" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/ard.2004.024109" "Revista" => array:6 [ "tituloSerie" => "Ann Rheum Dis" "fecha" => "2005" "volumen" => "64" "paginaInicial" => "638" "paginaFinal" => "640" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15769921" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0035" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Imaging in the crystal arthropathies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "F. McQueen" 1 => "A. Doyle" 2 => "N. Dalbeth" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rheum Dis Clin N Am" "fecha" => "2014" "volumen" => "40" "paginaInicial" => "231" "paginaFinal" => "249" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0040" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Crystal-associated synovitis-ultrasonographic feature and clinical correlation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D. Fodor" 1 => "A. Albu" 2 => "C. Gherman" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Orthop Traumatol Rehabil" "fecha" => "2008" "volumen" => "10" "paginaInicial" => "99" "paginaFinal" => "110" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735743/0000001300000004/v1_201707050008/S2173574317300357/v1_201707050008/en/main.assets" "Apartado" => array:4 [ "identificador" => "5795" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Images in Clinical Rheumatology" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735743/0000001300000004/v1_201707050008/S2173574317300357/v1_201707050008/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574317300357?idApp=UINPBA00004M" ]
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| 2020 September | 45 | 27 | 72 |
| 2020 August | 37 | 17 | 54 |
| 2020 July | 21 | 15 | 36 |
| 2020 June | 45 | 17 | 62 |
| 2020 May | 50 | 11 | 61 |
| 2020 April | 17 | 12 | 29 |
| 2020 March | 19 | 7 | 26 |
| 2020 February | 1 | 0 | 1 |
| 2018 May | 4 | 1 | 5 |
| 2018 April | 44 | 8 | 52 |
| 2018 March | 90 | 5 | 95 |
| 2018 February | 31 | 7 | 38 |
| 2018 January | 37 | 4 | 41 |
| 2017 December | 27 | 10 | 37 |
| 2017 November | 36 | 8 | 44 |
| 2017 October | 26 | 5 | 31 |
| 2017 September | 27 | 9 | 36 |
| 2017 August | 38 | 23 | 61 |
| 2017 July | 49 | 33 | 82 |
| 2017 June | 10 | 12 | 22 |
| 2017 May | 15 | 12 | 27 |
| 2017 April | 7 | 15 | 22 |
| 2017 March | 2 | 3 | 5 |
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