00:02
Now, that we've
completed discussion of the gout,
which by definition is
accumulation of what?
Uric acid.
00:08
Here we'll take a look at
what's known as
Calcium Pyrophosphate
Deposition Disease, or CPPD.
00:15
You probably commonly in med school,
and in your medical career
have come across
as being pseudogout.
00:20
I'll tell you why.
I want you to stay away from that,
because you need to understand
the actual pathology.
00:27
So what is pseudogout?
Oh, pseudogout is not the
accumulation of uric acid.
00:32
So therefore, it's not gout.
Pseudo, false.
00:35
So what is it?
It's accumulation of calcium.
Focus on that.
00:40
The full name is
pyrophosphate.
00:42
And the full name is
Calcium Pyrophosphate
Deposition Disease. CPPD. Correct?
I told you to focus on calcium.
Why?
Because presentation, especially
when I give you the X-ray.
00:54
I'm going to show you, that there's
going to be accumulation of calcium.
00:57
What color does calcium appear
on X-ray?
Opaque or loosened?
Good, opaque.
01:05
So I'll show you something
called chondrocalcinosis.
01:07
And while we go through this,
obviously, you're going to
compare this with the gout.
01:12
And you'll see how simple it is.
01:14
Pathogenesis, deposition of the
calcium pyrophosphate.
01:19
Most commonly, where?
Well, remember, in gout.
01:22
Where was the patient
complaining of pain acute?
In the big toe. Right?
Watching the football game.
"Oh, it hurts. Stop it."
Yeah. Well, this is the large joints
that you're looking for here
in the pseudogout or CPPD.
01:37
Next, I told you to
focus on calcium.
01:39
Chondro means cartilage.
01:40
So, in your joints,
such as a knee and such.
01:44
You're [inaudible]
going to accumulate calcium
called chondrocalcinosis.
01:47
So, the meniscus of the knee,
maybe the pubic symphysis
and maybe the wrists.
01:52
These are large joints.
01:54
Now there are associations.
01:56
Metabolic disorders, such as:
hyperparathyroidism.
02:01
What does that mean to you?
Oh, increase calcium. There you go.
02:04
Maybe hemochromatosis association.
Keep that in mind.
02:07
Could be hypothyroidism,
hypomagnesemia,
hypophosphatemia,
and Wilson's disease,
in other words, copper.
02:14
So there's important endocrine
or electrolyte association
that you want to keep in mind
with deposition of CPPD.
02:24
Signs and symptoms.
02:25
Patient typically presents
with acute symmetric arthritis.
02:30
What was it in gout?
It was one toe, podagra,
asymmetric, monoarticular.
02:37
These episodes are
usually triggered by surgery,
secondary to volume shifts,
or even severe illness.
02:42
Keep that in mind.
02:45
And then, so we talked about
how you could have pseudogout.
02:50
In other words, you know,
the pain could be acute,
it could be monoarticular.
02:54
However,
over a long period of time,
let's say that the knee
has been involved, chronically.
03:00
But the presentation now,
kind of feels like
a wear and tear type of pain.
03:04
In other words,
patient wakes up in the morning,
it feels a little bit of stiffness,
but less than one hour,
maybe less than 30 minutes.
03:10
Seems like osteoarthritis,
but it's not.
03:13
On X-ray you find calcium
accumulating on the cartilage.
03:16
So therefore, in chronic CPPD,
we then call this
pseudo-osteoarthritis,
or the pain might be
greater than one hour.
03:27
Then this may seem like
rheumatoid arthritis,
you call this
pseudo-rheumatoid arthritis.
03:34
We haven't talked about
rheumatoid arthritis yet.
03:36
But this is all about depositing
calcium pyrophosphate.
03:40
Acute, chronic.
03:42
So we have pseudogout, or
we have pseudo-osteoarthritis,
or pseudo-rheumatoid arthritis.
03:48
Keep that in mind for chronicity.
03:52
The calcium pyrophosphate
now these are rhomboid.
03:56
What shaped were the gout crystals?
Uric acid crystals?
They were needle like,
weren't they?
What was the type of light
that we use
to identify the needles of gout?
Polarized light.
04:09
Remind me again in gout,
those uric acid crystals,
were they negative or positive
birefringent?
In gout,
it was negative birefringent.
04:19
If it was negative birefringent
on polarized light,
on parallel,
was it yellow or blue?
Yellow.
04:28
Completely different
when we talked about CPPD.
04:30
Here we slightly
positively birefringent,
under polarized light.
04:39
Now, for you use parallel light,
for positive,
Guess what color that is?
Blue.
04:48
So the biggest difference so far in
polarized light has been with CPPD.
04:53
On parallel light,
it will be positively birefringent,
and he know it,
because on parallel it will be blue.
05:00
If done parallel, it's yellow.
That means it's negative.
05:04
Number one differential, gout.
Is that understood?
If not, make sure you repeat
what I just mentioned.
05:10
Extremely important.
05:13
Next, we'll talk about calcium.
05:15
And once again here
it is not uric acid, it's calcium.
05:19
So this made an appearance
soft tissue as well.
05:21
What color is calcium?
White on X-ray.
In other words, opaque.
05:28
Management of CPPD acutely
would be that similar to gout acute
or we have anti-inflammatory drugs,
such as NSAIDs.
05:39
You want to try to take care
the prophylaxis?
And prophylaxis usually
will be with colchicine.
05:45
Remember associations
that you could have
including hyperparathyroidism,
including hypothyroidism,
hypomagnesemia, hemochromatosis,
Wilson's, and such.
05:54
Associations that get
underlying issue as well.