Arthropathy and cutaneous calcinosis in hemodialysis oxalosis

Treatment of nongout joint deposition diseases: an update

This update develops the actual therapeutic options in the management of the joint involvement of calcium pyrophosphate deposition disease (CPPD), basic calcium phosphate (BCP) deposition disease, hemochromatosis (HH), ochronosis, oxalosis, and Wilson's disease. Conventional pharmaceutical treatment provides benefits for most diseases. Anti-interleukine-1 (IL-1) treatment could provide similar results in CPPD than in gout flares. There is only limited evidence about the efficacy of preventive long-term colchicine intake, methotrexate, and hydroxychloroquine in chronic CPPD. Needle aspiration and lavage have satisfactory short and midterm results in BCP. Extracorporeal shockwave therapy has also proved its efficacy for high-doses regimes. Phlebotomy does not seem to have shown real efficacy on joint involvement in HH so far. Iron chelators' effects have not been assessed on joint involvement either, while IL-1 blockade may prove useful. NSAIDs have limited efficacy on joint involvement of oxalosis, while colchicine and steroids have not been assessed either. The use of nitisinone for ochronotic arthropathy is still much debated, but it could provide beneficial effects on joint involvement. The effects of copper chelators have not been assessed either in the joint involvement of Wilson's disease. NSAIDs should be avoided because of the liver affection they may worsen.

Joint aspiration and injection and synovial fluid analysis

Joint aspiration/injection and synovial fluid (SF) analysis are both invaluable procedures for the diagnosis and treatment of joint disease. This chapter addresses (1) the indications, technical principles, expected benefits and risks of aspiration and injection of intra-articular corticosteroid and (2) practical aspects relating to SF analysis, especially in relation to crystal identification. Intra-articular injection of long-acting insoluble corticosteroids is a well-established procedure that produces rapid pain relief and resolution of inflammation in most injected joints. The knee is the most common site to require aspiration although any non-axial joint is accessible for obtaining SF. The technique involves only knowledge of basic anatomy and should not be unduly painful for the patient. Provided sterile equipment and a sensible, aseptic approach are used, it is very safe. Analysis of aspirated SF is helpful in the differential diagnosis of arthritis and is the definitive method for diagnosis of septic arthritis and crystal arthritis. The gross appearance of SF can provide useful diagnostic information in terms of the degree of joint inflammation and presence of haemarthrosis. Microbiological studies of SF are the key to the confirmation of infectious conditions. Increasing joint inflammation associates with increased SF volume, reduced viscosity, increasing turbidity and cell count and increasing ratio of polymorphonuclear:mononuclear cells, but such changes are non-specific and must be interpreted in the clinical setting. However, detection of SF monosodium urate and calcium pyrophosphate dihydrate crystals, even from un-inflamed joints during intercritical periods, allows a precise diagnosis of gout and calcium pyrophosphate crystal-related arthritis.

[Synovial fluid analysis]

At present, the study of the synovial fluid (SF) is a tool that is used frequently in specialized laboratories because it allows the establishment of diagnosis of crystal associated arthropathies, supports the diagnosis of septic arthritis and helps establish other rheumatologic diagnoses such as monoarthritis or joint effusion. The complete study of the SF includes the following analyses: 1. Macroscopic; 2. Microscopic; and 3. Specific stains. Each one provides information of the joint's state and helps in the establishment of diagnosis and treatment. The characteristics that must be described in the macroscopic analysis are: color, volume and viscosity. Microscopic analysis of the SF confirms the presence of an inflammatory or infectious processes and allows for the detection and identification of crystals. Polarized light microscope is a fundamental tool for the analysis of SF and for the identification of the crystals present in the samples, which not only depend on the form, but also of their birefringence. It is important to mention that in the microscopic analysis, artifacts can confuse the inexperienced observer. A suitable interpretation of the analysis of SF requires the observation by at least two experienced observers. The information that the analysis of SF provides to the clinicians gives them the necessary elements to establish the diagnosis and to decide on treatment. Specific stains in the analysis of SF help in the identification of non-birefringent crystals as those of calcium hydroxypatite. In SF analysis, new fields are being explored that include quantification of cytokines, chemokines, immunoglobulins and the characterization of cell lineages.

Joint aspiration and injection and synovial fluid analysis

Joint aspiration/injection and synovial fluid (SF) analysis are both invaluable procedures for the diagnosis and treatment of joint disease. This chapter addresses: (1) the indications, the technical principles and the expected benefits and risks of aspiration and injection of intra-articular corticosteroid; and (2) practical aspects relating to SF analysis, especially in relation to crystal identification. Intra-articular injection of long-acting insoluble corticosteroids is a well-established procedure that produces rapid pain relief and resolution of inflammation in most injected joints. The knee is the most common site to require aspiration, although any non-axial joint is accessible for obtaining SF. The technique requires a knowledge of basic anatomy and should not be unduly painful for the patient. Provided sterile equipment and a sensible, aseptic approach are used, it is very safe. Analysis of aspirated SF is helpful in the differential diagnosis of arthritis and is the definitive method for diagnosis of septic arthritis and crystal arthritis. The gross appearance of SF can provide useful diagnostic information in terms of the degree of joint inflammation and presence of haemarthrosis. Microbiological studies of SF are the key to the confirmation of infectious conditions. Increasing joint inflammation is associated with increased SF volume, reduced viscosity, increasing turbidity and cell count, and increasing ratio of polymorphonuclear: mononuclear cells, but such changes are non-specific and must be interpreted in the clinical setting. However, detection of SF monosodium urate and calcium pyrophosphate dihydrate crystals, even from un-inflamed joints during intercritical periods, allow a precise diagnosis of gout and of calcium pyrophosphate crystal-related arthritis.

Non-crystalline and crystalline rheumatic disorders in chronic kidney disease

Rheumatic syndromes are cause for morbidity in patients with end-stage renal disease. Recent advances in understanding the role of tissue remodeling have provided insight into the pathogenic mechanisms responsible for some of these manifestations. Here, we survey recent and clinically relevant advances in translational research that impact our understanding of rheumatic syndromes seen in patients with significant renal disease. The management of acute and chronic crystalline arthropathies in chronic kidney disease and hemodialysis patients is discussed.

Skeletal features of primary hyperoxaluria type 1, revisited

PURPOSE

The purpose of this study was to describe the skeletal manifestations of primary hyperoxaluria type 1 (PH1), the most common of the primary hyperoxalurias.

METHODS

We clinically and radiographically reviewed 12 consecutive patients diagnosed with PH1, aged between 2 and 17 years. All patients had evidence of some type of renal involvement, 4 of whom were at end-stage renal disease (ESRD) and were under dialysis.

RESULTS

The main symptom was skeletal pain and was present only in the 4 severely involved patients and appeared during the second year of dialysis. The 2 most severely involved patients had evidence of pathological fractures. Radiological signs were present in patients with or without symptoms. These radiological signs were of two distinct types: those almost specific of oxalosis, such as dense and radiolucent metaphyseal bands and vertebral osteocondensations, which are found mainly in the severely involved individuals, and those less specific, such as signs of renal osteodystrophy, which are also found in less severely involved patients. Interestingly, our study revealed the presence of spondylolysis in 25% of cases. This latter finding is unique and has not previously been reported in the literature.

CONCLUSIONS

The skeletal manifestations of PH1 include specific and less specific radiological signs, with some patients being asymptomatic, and others presenting with bone pain and pathological fractures, as well as spondylolysis.

Misdiagnosis of a chylous cyst as chest wall gouty tophus: a case of true pseudogout

A patient referred to us for recurrent chest wall gouty tophus, but who was determined to actually have a chylous cyst, is described herein. Chylous cysts of the neck or chest wall can be caused by thoracic duct injury. Chyle contains 4-40 gm/liter of lipids, mostly triglycerides, and these can form birefringent crystals upon drying, leading to a false diagnosis of gout.

Metabolic diseases: gout

Gout is a disease of antiquity but is increasing once again in prevalence despite availability of reasonably effective treatments. This may be related to a combination of factors, including diet, obesity, and diuretic use. Allergic reactions, noncompliance, drug interactions, and sometimes inefficacy all limit the effective use of current hypouricemic agents. There are new treatments for gout on the horizon, including febuxostat, a nonpurine inhibitor of xanthine oxidase with a potentially better combination of efficacy and side effects than allopurinol. Diagnostic progress is being made in that ultrasound may offer a noninvasive means of diagnosing tophaceous deposits in and around joints. The increasing prevalence of gout means that dermatologists will see more cutaneous manifestations of gout, including tophi, draining sinus tracts, panniculitis, and dystrophic calcifications.

Calcium oxalate saturation in dialysis patients with and without primary hyperoxaluria

Calcium oxalate supersaturation of the blood is associated with deposition of crystals in various tissues. We measured the serum levels of oxalate, citrate, calcium, and magnesium to estimate their saturation in 112 hemodialysis patients without primary hyperoxaluria and two boys with primary hyperoxaluria. Serum levels of oxalate and citrate were determined by high-performance capillary electrophoresis, while calcium and magnesium were measured by ICP spectroscopy. The serum levels of oxalate, citrate, calcium, and magnesium were 44.9+/-16.5, 138.1+/-54.9 micromol/l, 2.30+/-0.28, and 1.07+/-0.18 mmol/l, respectively, while the levels in patients with primary hyperoxaluria were 83.9+/-34.3, 197.9+/-63.5 micromol/l, 2.53+/-0.15, and 1.14+/-0.34 mmol/l, respectively. Serum calcium oxalate saturation (SS), as calculated by the Equil program, was significantly correlated with the serum oxalate level. Most patients showed metastable supersaturation (1<SS<8.9), which was associated with a serum oxalate level of more than 30 micromol/l. Serum saturation exceeded the formation product (SS=8.9) in some specimens from patients with type 1 primary hyperoxaluria. The serum calcium oxalate saturation [SS(CaOx)] showed a significant positive correlation with the levels of oxalate [Ox], calcium [Ca], and citrate [Cit]: [SS(CaOx)]=-0.3562+34.634[Ox]+0.394[Ca]-0.483[Mg]+0.101[Cit], (all mmol/l, r=0.9848, P<0.01). This formula is useful for estimating the saturation. In conclusion, the serum oxalate level is a good indicator of calcium oxalate saturation and should be monitored accurately while keeping it lower in dialysis patients.

Synovial fluid analysis

Synovial fluid (SF) accumulates in the joint cavity in different conditions; this review outlines the data from those analyses that help in their differential and definitive diagnosis. The gross appearance of the fluid can provide a quick bedside orientation with regard to the amount of inflammation present in the joint: totally transparent SF originates in non-inflammatory conditions--of which osteoarthritis is the most common--and the amount of turbidity grossly relates to the amount of inflammation. Most turbid to purulent fluids usually come from infected joints, but exceptions are not uncommon. The white cell count offers quantitative information, but the boundaries between non-inflammatory and inflammatory SF and between this and septic fluid are very hazy and figures have to be interpreted in the clinical setting. Detection and identification of monosodium urate (MSU) and calcium pyrophosphate dihydrate (CPPD) crystals allow a precise diagnosis of gout and CPPD crystal-related arthropathy. Only one in five CPPD crystals have sufficient birefringence for easy detection and they are easily missed if searched for only using a polarised microscope. Instructions for beginners are given. Proper microbiological studies of the SF is the key to the diagnosis of infectious conditions.

Cutaneous ectopic breast calcification in a haemodialysis patient

This case report details the unique breast calcification and swellings of a 61-year-old lady. The ectopic breast calcification was a result of chronic renal failure and hyperparathyroidism secondary to vesiculo-ureteric reflux nephropathy. Subcutaneous nodules were also noted around her ileostomy (from surgery due to Crohn's disease) and abdominal wall. Mammogram revealed calcified breast discs and lobules with extensive vascular calcification. Histological biopsies revealed extensive calcium deposition (benign). Cutaneous deposition of calcium oxalate has been described in 13 patients world wide, usually involving fingers, ears, or nose. Two of these report breast involvement, but this is described as less extensive and more focal calcification on clinical findings and mammography. This case report describes a rare condition with extraordinary mammographic images.

Arthroscopic synovectomy for the management of shoulder arthropathy in chronic renal dialysis patients

We present the clinical results of 7 hemodialysis patients after arthroscopic shoulder synovectomy (1 bilateral) for night pain and decreased range of motion. There was no evidence of infection in any of the shoulders at the time of surgery. The results of histologic analysis of synovial tissue were negative for crystals in all of the patients. Tissue from 1 of 7 patients was positive for amyloid. All 7 patients had significant pain relief at a mean of 2.3 months postoperatively. At a mean of 5.5 years postoperatively, the mean L'Insalata score was 68.8 +/- 12.2 points. Five of six patients rated their overall satisfaction with the procedure as good or excellent. Forward flexion and external rotation had improved by a mean of 40 degrees and 20 degrees, respectively. The mean American Shoulder and Elbow Surgeons score was 64.5 +/- 13.1 points. We believe that arthroscopic synovectomy is an effective treatment for hemodialysis patients who have shoulder pain, particularly night pain that is not caused by infection and fails to respond to conservative management.

Arthritis in the intensive care unit

Acute arthritis in critically ill patients may be caused by local or systemic infection, by a flare of chronic joint disease such as rheumatoid or crystal-associated arthritis, or by less common entities such as hemarthrosis. Diagnosis requires analysis of synovial fluid, and appropriate treatment is based on its findings. Prompt diagnosis and treatment are usually necessary to prevent the significant morbidity associated with these conditions.

Oxalate crystal deposition disease

In addition to monosodium urate, calcium pyrophosphate dihydrate, and apatite crystals, oxalate crystals are less often found in synovial fluids in association with acute or chronic arthritis. Oxalate crystal deposition disease is seen in patients with primary hyperoxaluria types 1 and 2 (PH1 and 2) and in patients with end-stage renal disease managed with long-term dialysis. Oxalate crystal deposits are found mainly in kidneys, bone, skin, and vessels, and less often inside the joints. Musculoskeletal and systemic manifestations of oxalate crystal deposition disease may be confused with those observed with the other most common types of crystal deposition diseases. Clinical and radiographic features include calcium oxalate osteopathy, acute and chronic arthropathy with chondrocalcinosis, synovial calcification, and miliary skin calcium oxalate deposits and vascular calcifications that affect mainly the hands and feet. Systemic life-threatening cardiovascular, neurologic, and hematologic manifestations are rare. Genomic DNA studies have identified those genetic defects of PH1 and PH2 that allow a precise early diagnosis. Kidney transplantation has poor outcome as a result of graft oxalosis. Combined liver and kidney transplantation is the treatment of choice in patients with PH1 and advanced renal failure. Pre-emptive isolated liver transplantation is the preferred treatment in patients who develop the disease during infancy with progressive manifestations of oxalosis. These novel findings in the understanding of the molecular and enzymatic aspects of primary hyperoxalurias have provided a more rational basis for the management and prevention of oxalate crystal deposition disease. This information may lead to a better understanding and effective management of other common calcium-containing crystal deposition diseases.

Do we really need to pay attention to the less common crystals?

In addition to monosodium urate, calcium pyrophosphate dihydrate, and apatite crystals, a wide variety of less common crystals, artifacts, and, occasionally, some unidentified birefringent materials may be seen in synovial fluids in association with acute or chronic arthritis. These unusual crystals and their associated musculoskeletal manifestations may be confused with the more common crystals and their manifestations and sometimes may provide the clue for systemic disease because they may present with a pseudovasculitis syndrome. Important advances in understanding the molecular aspect and management of primary hyperoxalurias as well as nephropathic cystinosis provide important general information to be applied in research and in the search for a more effective management of other common crystal-induced arthritis.

Symptomatic spinal calcinosis in systemic sclerosis (scleroderma)

Two patients with diffuse cutaneous systemic sclerosis and spinal calcification, involving the lumbar spine in one and the cervical spine in the other, are described. Computed tomography-guided aspiration of the calcific masses was performed, and material aspirated from one patient was shown to be apatite, Ca5(PO4)3OH. One patient showed improvement following lumbar laminotomy, hemilaminectomy, and diskectomy.

The application of atomic force microscopy for the detection of microcrystals in synovial fluid from patients with recurrent synovitis

Synovial fluid from 33 patients with inflammatory arthritis was examined with a polarized light microscope (PLM) and an atomic force microscope (AFM). Two samples were imaged with a transmission electron microscope (TEM) to determine calcium/phosphate ratios and identify microcrystals of calcium pyrophosphate dihydrate and octacalcium phosphate. Additional correlative x-ray diffraction studies were performed on several samples including purified hydroxyapatite and sodium chloride crystals. Monosodium urate, calcium pyrophosphate dihydrate, hydroxyapatite, octacalcium phosphate, and cholesterol crystals were identified with AFM. AFM images of these microcrystals revealed detailed surface topology, including lattice parameters and structural irregularities at the crystals' surface. These features were consistent with those obtained by TEM and x-ray diffraction studies. In addition, AFM images revealed that some specimens contained microcrystals that were undetected by PLM and/or TEM. These results suggest that AFM may provide a simple yet powerful technique for the detection of microcrystals in synovial fluid taken from patients with crystal-induced arthritis.

Cutaneous oxalate deposition in a hemodialysis patient

We describe calcium oxalate and amyloid arthropathy with cutaneous calcinosis without vitamin C supplement. A 34-year-old woman developed glomerulonephritis requiring chronic hemodialysis. Seven years after beginning hemodialysis, multiple crystal deposits appeared in her skin; she also presented with arthralgia and gait disturbance. A skin biopsy was performed, which disclosed calcium oxalate deposition. In addition, a right femoral neck prosthetic replacement was performed. Pathologic examination of the hip synovia revealed diffuse calcium oxalate, amyloid, and iron deposition. Calcium oxalate and amyloid arthropathy with synovial hemosiderosis was diagnosed, and therapy with desferal and high-flux membrane dialysis was started. Clinical improvement occurred after 6 months.

Secondary cutaneous oxalosis: cutaneous deposition of calcium oxalate dihydrate after long-term hemodialysis

A 48-year-old Japanese man had miliary calcified papules on the distal fingers after long-term hemodialysis. The crystals in the dermis consisted of calcium oxalate, as revealed by light microscopy and scanning electron microscopy with energy-dispersive x-ray microanalysis. The calcium oxalate was in the form of a dihydrate crystal. Therefore a diagnosis of secondary cutaneous oxalosis was made. In cutaneous oxalosis that occurs as a result of hemodialysis, miliary deposits occur in the fingers, but not the toes, and are present more frequently on the palmar aspects of the fingers. This localization may result from local differences in the metabolism or concentration of calcium or oxalate, or changes in the blood circulation.

Cutaneous oxalate granulomas in a haemodialysed patient: report of a case with unique clinical features

We report a patient undergoing haemodialysis, who developed multiple subcutaneous nodules. Histology showed that the nodules were composed of deposits of crystals in the dermis, with an associated foreign-body reaction. The crystalline deposits were identified as calcium oxalate by histochemical staining, polarizing microscopy, and analytical electron microscopy.

Superoxide anion production and phagocytosis of crystals by cultured endothelial cells

OBJECTIVE

To show that cultured human umbilical vein endothelial cells (HUVEC) are capable of phagocytizing inflammation-causing crystals and of generating superoxide anion (SOA) during phagocytosis.

METHODS

The superoxide dismutase-inhibitable reduction of nitroblue tetrazolium (NBT) dye was used as a measure of SOA production. Phagocytosis was quantified by light microscopy and confirmed by transmission electron microscopy. Cytochrome C was also studied but was found to undergo spontaneous reduction by monosodium urate (MSU) without cells.

RESULTS

Crystals of MSU, calcium oxalate, hydroxyapatite, and calcium pyrophosphate dihydrate (CPPD) were phagocytized and, except for the CPPD crystals, induced NBT reduction. Cholesterol and cholesterol monohydrate were neither phagocytized nor did they induce NBT reduction.

CONCLUSIONS

Endothelial cells may be a significant source of oxygen radicals in crystal-associated and other arthritides.

Hand manifestations of oxalosis

Oxalosis is an unusual metabolic disease that results either from an inherited hepatic enzyme deficiency or as the result of poor oxalate clearance during chronic hemodialysis. We present two cases of oxalosis and describe the hand manifestations of this condition and their treatment. One patient had painful, progressive gangrene, whereas in the other the disease took an indolent course with small palmar crystalline deposits.

Some commonly unrecognized manifestations of metabolic arthropathies

The metabolic arthropathies are characterized by the deposition of abnormal substances in or around joints. Certain features of some of these arthropathies and their significance have only recently been recognized and others have been insufficiently emphasized. An important group of conditions are the arthropathies related to renal failure and its treatment, namely, aluminum toxicity, periarticular calcification and crystal deposition, hyperparathyroidism, and dialysis-related amyloidosis. Crystal deposition diseases, specifically, gouty arthritis, calcium pyrophosphate deposition, and calcium hydroxyapatite deposition, are also reviewed.

Clinical and histologic features of primary oxalosis

Primary oxalosis should be considered in patients with multisystem disease of the kidneys, heart, peripheral vasculature, and skin. Crystalline deposits can lead to nephrolithiasis with kidney failure, complete heart block, peripheral vasospasm, and livedo reticularis, as in our patient. Crystals were first observed in the myocardial biopsy specimen and then identified as calcium oxalate in skin from an area of livedo reticularis.

Hydroxyapatite pseudopodagra. A syndrome of young women

Six women with acute calcific periarthritis of the first metatarsophalangeal joint (hydroxyapatite pseudopodagra) are described, and 10 previously reported cases (8 female patients and 2 male patients) are reviewed. The onset was characterized by acute pain, swelling, erythema, tenderness, and limitation of movement of the first metatarsophalangeal joint, symptoms indistinguishable from those of gouty podagra, which is associated with transient amorphous calcific deposits in the vicinity of the joint. Based on these results it appears that hydroxyapatite pseudopodagra is a disorder that predominantly affects premenopausal women.

Calcium oxalate and other crystals associated with kidney diseases and arthritis

The recognition of tissue deposits of crystalline material in a variety of organs, including the kidney, predated the association of crystals and arthritic disease. Because of this, the pathophysiology of crystal formation and its resultant inflammation is based in part on studies of renal stones. A number of disease states involving renal and articular crystallization exist. The most common of these, uric acid precipitation, or gout, and calcium phosphate precipitation were not reviewed in this discussion. This review described a variety of less common disease states involving articular and renal crystal deposition. The renal diseases discussed included both parenchymal or ectopic crystal deposition, as seen in nephrocalcinosis or cystinosis, and ductal crystallization as seen in renal calculus disease. The crystals involved included not only calcium oxalate, but also aluminum, amino acids and proteins (cystine, hemoglobin, cryoglobulins, and immunoglobulins), purine metabolites (xanthine, hypoxanthine), and even lipids and their degradative enzymes (cholesterol, phospholipids, phospholipase, and fatty acids). The simultaneous occurrence of crystals in both kidneys and joints was found in some cases to result from the systemic deposition of an excess of a particular biological compound. However, of more interest, some renal deposits were shown to more selectively reflect the normal or abnormal function of the kidney in its secretory and excretory roles. This is particularly evident in the variety of arthritic states described in end-stage renal disease.