Images in Clinical Rheumatology
Mixed crystal arthropathy of the wrist: The contribution of imaging in the diagnostic approach
Artropatía cristalina mixta de la muñeca: la contribución de la imagen en el enfoque diagnóstico
Nikita Khmelinskii
, Joaquim Polido-Pereira
Corresponding author
Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon Academic Medical Centre, Lisbon, Portugal
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Thickening of the soft tissues at the level of the distal fingers. Marked destructive changes with acro-osteolysis in all of the distal fingers (arrowed), with formation of flat surfaces in both the fifth fingers, bone proliferation at the level of the left radius and more discretely at the base of several distal fingers (arrow points). (B) Oblique X-ray of the right foot. 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(A) Longitudinal view of the distal ulna, with grey-scale grade 2 synovitis of the distal radio-ulnar joint (asterisk). (B) Transverse view of the distal radio-ulnar joint, with an intrahyaline hyperechoic band parallel to the surface of the distal ulnar cartilage (arrows). (C) Several hyperechoic spots with a “punctate pattern” of the triangular fibrocartilage complex (arrow heads). L – lunate; R – radium; U – ulna.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 40-year-old man with a history of binge drinking and childhood right wrist fracture presented with acute pain, oedema and functional impotence of the right wrist. On physical examination, erythema and oedema of the distal forearm and wrist, and pain elicited by wrist pronation/supination were noted.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Ultrasound examination revealed distal radio-ulnar synovitis, a hyperechoic band within the distal cubital cartilage, and several hyperechoic spots of the triangular fibrocartilage complex (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), compatible with calcium pyrophosphate dihydrate (CPP) crystal deposition (CPPD).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Plain radiography showed radio-carpal joint space narrowing, subchondral sclerosis of the joint margins, and linear calcifications of the distal radio-ulnar and radio-carpal joints (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Ultrasound-guided joint aspiration was performed. Polarized microscopy of the synovial fluid showed numerous monosodium urate monohydrate (MU) and rare CPP crystals. The patient's uric acid level was 9.1<span class="elsevierStyleHsp" style=""></span>mg/dL. No other metabolic abnormalities were noted. Treatment with colchicine ensured rapid symptom relief and urate-lowering therapy with allopurinol was started four weeks later.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Up to 2.5% of patients with crystal induced arthritis may have coexistent CPP and MU crystals.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> The identification of characteristic birefringent crystals remains essential for the diagnosis of CPPD or gout.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2,3</span></a> Ultrasonography is a valuable tool for performing guided intra or periarticular diagnostic and therapeutic injections.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> Likewise, growing evidence on its utility in identifying crystal deposits has led to the incorporation of ultrasound findings in CPPD and gout classification criteria.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2,3</span></a> In gout, the deposits appear as an irregular hyperechoic enhancement over the surface of the hyaline cartilage – the double-contour sign.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> In CPPD, the hyperechoic deposits are of variable shape and typically localized within the fibrocartilage or hyaline cartilage (parallel to the surface of the cartilage).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> Moreover, ultrasonography showed higher sensitivity than radiography and similar accuracy to synovial fluid analysis for detecting CPPD.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">6,7</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-10-29" "fechaAceptado" => "2017-10-31" "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2747 "Ancho" => 1500 "Tamanyo" => 269950 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ultrasound images of the right wrist. (A) Longitudinal view of the distal ulna, with grey-scale grade 2 synovitis of the distal radio-ulnar joint (asterisk). (B) Transverse view of the distal radio-ulnar joint, with an intrahyaline hyperechoic band parallel to the surface of the distal ulnar cartilage (arrows). (C) Several hyperechoic spots with a “punctate pattern” of the triangular fibrocartilage complex (arrow heads). L – lunate; R – radium; U – ulna.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2258 "Ancho" => 1500 "Tamanyo" => 596639 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Radiography images of the wrists. (A) Anteroposterior projection, with radio-carpal joint space narrowing and subchondral sclerosis of the radium of the right wrist. (B) Detail of the right wrist, with linear calcifications of the distal radio-ulnar and radio-carpal joints (arrows).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Synovial fluid findings and demographic analysis of patient with coexistent intra-articular monosodium urate and calcium pyrophosphate crystals" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "E.L. Heselden" 1 => "A.J. Freemon" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/RHU.0000000000000321" "Revista" => array:6 [ "tituloSerie" => "J Clin Rheumatol" "fecha" => "2016" "volumen" => "22" "paginaInicial" => "68" "paginaFinal" => "70" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26906297" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0045" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "European League Against Rheumatism recommendations for calcium pyrophosphate deposition. Part I: Terminology and diagnosis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "W. Zhang" 1 => "M. Doherty" 2 => "T. Bardin" 3 => "V. Barskova" 4 => "P.-A. Guerne" 5 => "T.L. 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