Abstract
Background A 79-year-old woman was referred for evaluation of her painful and swollen joints. She had a medical history of congestive heart failure, renal insufficiency and peptic ulcer disease. For the past 3 years she had experienced recurrent bouts of debilitating arthritis, lasting approximately 3–4 weeks at a time. The symptoms were most severe in the hands and knees, where the joints were warm, swollen and tender. During each flare-up, the patient was housebound and required therapeutic dosing of nonsteroidal anti-inflammatory drugs and codeine to control joint pain.
Investigations Physical examination, fine-detailed radiographs of the hands, standing radiographs of the knees, arthrocentesis including cell count and gram stain, compensated polarized light microscopy, alizarin-red staining, X-ray diffraction, scanning and transmission electron microscopy with energy dispersive spectrometry, electron microprobe analysis with energy dispersive spectrometry, Fourier transform infrared spectroscopy, and atomic force microscopy.
Diagnosis Carbonated-substituted apatite arthropathy.
Management Both knees were aspirated and large volumes of a straw-colored synovial fluid was removed. The knees were injected with corticosteroid, resulting in excellent symptomatic response.
This is a preview of subscription content, access via your institution
Access options
Subscribe to this journal
Receive 12 print issues and online access
$209.00 per year
only $17.42 per issue
Buy this article
- Purchase on SpringerLink
- Instant access to full article PDF
Prices may be subject to local taxes which are calculated during checkout
References
Derfus B et al. (2002) The high prevalence of pathologic crystals in pre-operative knees. J Rheumatol 29: 570–574
Schumacher HR Jr (1987) Crystals, inflammation, and osteoarthritis. Am J Med 83 (Suppl 5A): S11–S16
Halverson PB et al. (1986) Patterns of radiographic abnormalities associated with basic calcium phosphate and calcium pyrophosphate dehydrate crystal deposition in the knee. Ann Rheum Dis 45: 603–605
McCarthy GM (2005) Crystal deposition diseases: out of sight, out of mind. Curr Opin Rheumatol 17: 312–313
Cheung HS (2005) Biologic effects of calcium-containing crystals. Curr Opin Rheumatol 17: 336–340
Halverson PB et al. (1998) Intracellular calcium responses to basic calcium phosphate crystals in fibroblasts. Osteoarthritis Cartilage 6: 324–329
Schumacher HR Jr (1995) Synovial inflammation, crystals, and osteoarthritis. J Rheumatol 22 (Suppl 43): S101–S103
Cheung HS et al. (1997) Calcium phosphate particle induction of metalloproteinase and mitogenesis: effect of particle sizes. Osteoarthritis Cartilage 5: 145–151
Prudhommeaux F et al. (1996) Variation in the inflammatory properties of basic calcium phosphate crystals according to crystal type. Arthritis Rheum 39: 1319–1326
Von Essen R et al. (1998) Quality control of synovial fluid crystal identification. Ann Rheum Dis 57: 107–109
Segal JB et al. (1999) Diagnosis of crystal-induced arthritis by synovial fluid examination for crystals: lessons from an imperfect test. Arthritis Rheum 12: 376–380
Schumacher R et al. (1977) Arthritis associated with apatite crystals. Ann Intern Med 87: 411–416
Dieppe P et al. (1976) Apatite deposition disease: a new arthropathy. Lancet 1: 266–269
McCarty D et al. (1966) Recurrent acute inflammation associated with focal apatite crystal deposition. Arthritis Rheum 9: 804–818
McCarty D et al. (1983) Crystal populations in human synovial fluid: identification of apatite, octacalcium phosphate, and tricalcium phosphate. Arthritis Rheum 26: 1220–1224
Blair JM et al. (1995) The application of atomic force microscopy for the detection of silicon-containing particles in synovial fluid: potential confusion with calcium pyrophosphate dehydrate and apatite crystals. Ann Rheum Dis 5: 359–369
Dieppe P et al. (1999) Identification of crystals in synovial fluid. Ann Rheum Dis 58: 261–263
McCarthy GM et al. (1994) The role of cyclic-3',5'-adenosine monophosphate in prostaglandin-mediated inhibition of basic calcium phosphate crystal-induced mitogenesis and collagenases induction in cultured human fibroblasts. Biochim Biophys Acta 1226: 97–104
Nair D et al. (1997) Phosphocitrate inhibits a basic calcium phosphate and calcium pyrophosphate dehydrate crystal-induced mitogen-activated protein kinase cascade signal transduction pathway. J Biol Chem 272: 18920–18925
Cheung HS (2001) Phosphocitrate as a potential therapeutic strategy for crystal deposition disease. Curr Rheumatol Rep 3: 24–28
Krug HE et al. (1993) Phosphocitrate prevents disease progression in murine progressive ankylosis. Arthritis Rheum 36: 1603–1611
Acknowledgements
The author wishes to thank Dr Verity Wilkins for her assistance in the preparation of this manuscript.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Competing interests
The author declares no competing financial interests.
Rights and permissions
About this article
Cite this article
Blair-Levy, J. Carbonated apatite-induced arthropathy: a consideration in cases of polyarthritis. Nat Rev Rheumatol 2, 278–283 (2006). https://doi.org/10.1038/ncprheum0174
Received:
Accepted:
Issue Date:
DOI: https://doi.org/10.1038/ncprheum0174