Gout pseudogout crystal

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

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Gout and pseudogout are the 2 most common crystal-induced forms of arthritis.

They are debilitating illnesses in which pain and joint inflammation are caused by the formation of crystals within the joint space.

Gout is inflammation caused by monosodium urate monohydrate (MSU) crystals.

Pseudogout is inflammation caused by calcium pyrophosphate (CPP) crystals and is sometimes referred to as calcium pyrophosphate disease (CPPD).

Gout is the most common crystal-induced arthritis.

Arthritis in patients with gout and pseudogout is caused by an inflammatory response triggered by the rupture of polymorphonuclear white blood cells that have ingested MSU crystals or CPP crystals. MSU crystals are formed in joint fluid when the fluid becomes supersaturated with MSU.

This supersaturation can result from overproduction or reduced excretion of MSU. Many conditions and drugs have been associated with an increase in blood and joint fluid urate levels. A genetic predisposition for the disease exists.

CPPD crystals are produced by nucleoside triphosphate pyrophosphohydrolase (NTPPPH), an enzyme found in osteoarthritic cartilage. A genetic predisposition exists for the condition, but any process that leads to osteoarthritis also can be associated with subsequent pseudogout.

Joint aspiration is the procedure used to make the diagnosis of crystal-induced arthritis and to rule out septic (infectious) arthritis.

Joint fluid should be evaluated for cell count and differential, Gram stain, culture and sensitivity, and microscopic analysis for crystals. If crystals are seen, their shape and appearance under polarized light can make tbhe diagnosis.

In gout, crystals of MSU appear as needle-shaped intracellular and extracellular crystals. When examined with a polarizing filter, they are yellow when aligned parallel to the axis of the red compensator, but they turn blue when aligned across the direction of polarization (ie, they exhibit negative birefringence).

In pseudogout, CPP crystals appear shorter and often rhomboidal. Under a polarizing filter, CPP crystals do not change color depending upon their alignment relative to the direction of the red compensator.

In crystal arthritis, the WBC count in the joint fluid is usually 50,000-100,000.

Gout can be put into remission with medication. Unfortunately, CPPD is difficult to treat and many experts disagree on the optimum management of the disease.

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