QD 73 - CPPD And PIP4 Save
QD Clinic - Lessons from the clinic
The Seronegative Patient with CPPD
YouTube link: https://youtu.be/TojVJJiL_vo
Transcription
This is QD clinic brought to you by RheumNow live. I'm doctor Jack Cush from rheumnow.com. This week, we have an interesting case. A 59 year old Latin male shows up with a swollen left fourth PIP. This one here.
Swollen contracted going on for about three months. He's previously diagnosed with seronegative RA, but he never quite responded to Enbrel, methotrexate, Plaquenil, or nonsteroidals. Turns out he's been best controlled in the last year with low dose steroids, two point five of prednisone, and nonsteroidal anti inflammatory drugs. He is rheumatoid factor, CCP negative, and on b a b twenty seven negative. He did have x rays of his hand showing no evidence of erosions, but did show evidence of chondrocalcinosis in the wrist.
So we had previously diagnosed him as having CPPD or, chronic, calcium pyrophosphate deposition disease. No episodes of acute pseudo gout, but nonetheless, he's been managed really quite well with low dose prednisone and nonsteroidals. Now he presents with a new swollen joint that hasn't gone down, and it's been going on three months. So the question is how can we best treat him and is this going to be in fact pseudogout or CPPD chronic arthropathy? As you know, these patients with the chronic arthropathy are a little bit higher to diagnose.
Acute pseudogout, not difficult, you know, attacks in the knees, wrists, are very common, feet, not uncommon, slightly different distribution than what you see with gout where it's mainly MTP, MTP, MTP, ankle, tarsus, and then it ascends with multiple attacks. Whereas in pseudogout, you might have them first attack in the wrist. So this gentleman has an attack in in he's never had a wrist attack, but he's had two attacks in PIPs in the past. And the question is, what is the, findings in pseudogout? Well, the number one finding in pseudogout and CPPD is chondrocalcinosis.
They tend to have normal mineralization unless they have, chronic inflammatory arthropathy. They have uniform joint space loss. They can have subchondral new bone formation. They tend to have more osteo, some osteophytes, more subchondral cyst than what you see in osteoarthritis, and they can occasionally have neuropathic changes. They tend to be bilateral in their findings, and the joints that are usually involved, as you know, are the wrist MCP two and three are not uncommon.
PIPs are can occur. In decreasing order, it's the knees, hands, hips, and then unlike osteoarthritis, you can get shoulder and elbow involvement with CPPD. So we were gonna treat this gentleman as if he had CPPD and recheck his x rays to see if anything has changed in that left fourth BIP, which means that he stays on the low dose prednisone two point five. Actually, we increased it to five for two weeks, and then we'll put him back at two point five. We're going to splint the finger, and hope that that gets better.
We put him on colchicine zero point six milligrams QD, and that's basically the treatment. And then when they get into a chronic arthropathy, you can treat them like RA. When they have acute arthropathy and you can't use the drugs that you already mentioned, there's good research that we talked about here about using anakinra injections, daily anakinra injections, one usually two, three or four of them to control the acute attack. Again, a good case, an interesting case of CPPD that's not so well controlled here in the clinic. Make sure you check out roomnow.live, roomnow.live, which is where you would go to register for our meeting.
I think what you'll like about the meeting is the fellowship. It begins on the first day on Friday. We end at 05:15, and we go right to the roof where we have a nice reception called RheumNow Distilled, where we have craft lemonade. I love craft lemonade. You may love craft beer or craft whiskey.
We've got great food. We hang out under the stars for a few hours, and then people drift off into the streets of Fort Worth where you can dine at, like, one of 25 different great restaurants in the area. So check it out. We'll see you in Fort Worth in a few weeks. Tune in for more QD video QD clinics.
Swollen contracted going on for about three months. He's previously diagnosed with seronegative RA, but he never quite responded to Enbrel, methotrexate, Plaquenil, or nonsteroidals. Turns out he's been best controlled in the last year with low dose steroids, two point five of prednisone, and nonsteroidal anti inflammatory drugs. He is rheumatoid factor, CCP negative, and on b a b twenty seven negative. He did have x rays of his hand showing no evidence of erosions, but did show evidence of chondrocalcinosis in the wrist.
So we had previously diagnosed him as having CPPD or, chronic, calcium pyrophosphate deposition disease. No episodes of acute pseudo gout, but nonetheless, he's been managed really quite well with low dose prednisone and nonsteroidals. Now he presents with a new swollen joint that hasn't gone down, and it's been going on three months. So the question is how can we best treat him and is this going to be in fact pseudogout or CPPD chronic arthropathy? As you know, these patients with the chronic arthropathy are a little bit higher to diagnose.
Acute pseudogout, not difficult, you know, attacks in the knees, wrists, are very common, feet, not uncommon, slightly different distribution than what you see with gout where it's mainly MTP, MTP, MTP, ankle, tarsus, and then it ascends with multiple attacks. Whereas in pseudogout, you might have them first attack in the wrist. So this gentleman has an attack in in he's never had a wrist attack, but he's had two attacks in PIPs in the past. And the question is, what is the, findings in pseudogout? Well, the number one finding in pseudogout and CPPD is chondrocalcinosis.
They tend to have normal mineralization unless they have, chronic inflammatory arthropathy. They have uniform joint space loss. They can have subchondral new bone formation. They tend to have more osteo, some osteophytes, more subchondral cyst than what you see in osteoarthritis, and they can occasionally have neuropathic changes. They tend to be bilateral in their findings, and the joints that are usually involved, as you know, are the wrist MCP two and three are not uncommon.
PIPs are can occur. In decreasing order, it's the knees, hands, hips, and then unlike osteoarthritis, you can get shoulder and elbow involvement with CPPD. So we were gonna treat this gentleman as if he had CPPD and recheck his x rays to see if anything has changed in that left fourth BIP, which means that he stays on the low dose prednisone two point five. Actually, we increased it to five for two weeks, and then we'll put him back at two point five. We're going to splint the finger, and hope that that gets better.
We put him on colchicine zero point six milligrams QD, and that's basically the treatment. And then when they get into a chronic arthropathy, you can treat them like RA. When they have acute arthropathy and you can't use the drugs that you already mentioned, there's good research that we talked about here about using anakinra injections, daily anakinra injections, one usually two, three or four of them to control the acute attack. Again, a good case, an interesting case of CPPD that's not so well controlled here in the clinic. Make sure you check out roomnow.live, roomnow.live, which is where you would go to register for our meeting.
I think what you'll like about the meeting is the fellowship. It begins on the first day on Friday. We end at 05:15, and we go right to the roof where we have a nice reception called RheumNow Distilled, where we have craft lemonade. I love craft lemonade. You may love craft beer or craft whiskey.
We've got great food. We hang out under the stars for a few hours, and then people drift off into the streets of Fort Worth where you can dine at, like, one of 25 different great restaurants in the area. So check it out. We'll see you in Fort Worth in a few weeks. Tune in for more QD video QD clinics.
If you are a health practitioner, you may Login/Register to comment.
Due to the nature of these comment forums, only health practitioners are allowed to comment at this time.