PSEUDOGOUT

Rosyimah

PRETEST
1. Pseudogout disebut juga .
A. MSU deposition
B. Calcium Pyrophosphate Dihydrate deposition
C. Basic calcium phosphate (BCP)
D. Calcium apatite deposition
2. Predisposing factors to crystal formation include ,except :
1.
2.
3.
4.

hypomagnesemia
peningkatan usia (aging)
hypophosphatasia
women < men

3. kondisi yang didasarkan atas ditemukannya kristal

kalsium pada pemeriksaan radiologis sebagai

radiolusen di sekitar sendi disebut
A. crystallography
B. calsiolusen
C. chondrocalcinosis
D. articulocalcinosis
4. Pseudogout .
1. small joint
2. pain intense
3. uric acid crystal
4. ca pyrophosphate crystal

5. bentuk Kristalnya pseudogout adalah

A. the weakly negative, birefringent,rhomboid-shaped calcium

pyrophosphate crystals

B. the weakly negative , birefringent,needle-shaped calcium

pyrophosphate crystals

C. the strongly positive, birefringent,rhomboid-shaped calcium

pyrophosphate crystals

D. the weakly positive, birefringent,needle-shaped calcium

pyrophosphate crystals

E. the weakly positive, birefringent,rhomboid-shaped calcium

pyrophosphate crystals

6. examination of synovial fluid in pseuddogout :

1.
2.
3.
4.
7.
a.
b.
c.
d.
e.

cloudy appereance
WBC (-)
normal viscosity
bactery (+)

Obat yang digunakan sebagai profilaksis pada pseudogout

Kolkisin iv
Kortikosteroid high doses
Oral kolkisisn
Fenilbutazon
MTX

8. lokasi tersering pseudogout .

A. The knee,wrist,first metatarsophalangeal joint
B. The knee,wrist,first metacarpophalangeal joint
C. sendi jari-jari tangan
D. only hip

9. Colchicine should be avoided in patients with

A. renal or hepatic disease
B. pregnancy
C. autoimun disease
D. cancer
10. dosis fenilbutazon yang digunakan sebagai terapi pseudogout
adalah
A. 400-600mg/hr
B. 500-700mg/hr
C.600-700mg/hr
D.1000-1200mg/hr

DEFINISI
Suatu kondisi metabolik artropati akibat akumulasi
kalsium pirofosfat di dalam tendon, ligamentum, kapsul
sendi, sinovium, dan kartilago.
CPPD deposition encompasses three overlapping
conditions:
(1) chondrocalcinosis the appearance of calcific
material in articular cartilage and menisci; didasarkan
atas ditemukannya kristal kalsium pada pemeriksaan
radiologis sebagai radiolusen di sekitar sendi.
(2) pseudogout a crystal-induced synovitis; and
(3) chronic pyrophosphate arthropathy a type of
degenerative joint disease.

ETIOLOGI
Predisposing factors to crystal formation
include
1. aging => meningkatkan kondrokalsinosis
2. familial predisposition
3. metabolic diseases (hypophosphatasia,
hyperparathyroidism, hemochromatosis,
Wilson disease, and hypomagnesemia)
4. osteoarthritis or trauma
5. women > men
6. enzymatic degradation.

PATOLOGY
timbunan kristal CPPD di dalam struktur
sendiKristal memicu proses
fagositosismelepaskan enzim-enzim
lisosomkeradangan.
Pembentukan kristal CPPD pada kartilago
disebabkan peningkatan kadar kalsium atau
pirofosfat inorganik (PPi) dari perubahan di dalam
matriks yang mencetuskan pembentukan kristal
atau dari kombinasi keduanya.
Sumber utama PPi secara biologis dari
pemecahan nukleotida trifosfat atau berhubungan
dengan senyawa( uridin difosfoglukose ) pada
kartilago.
CPPD juga dapat mengaktivasi faktor Hagemen

CPPD DEPOSITION DISEASE

PATHOGENESIS
in articular tissues
most common in the elderly, (1015% 6575 years and 3050% >85 years)
increased production of inorganic pyrophosphate and decreased levels of
pyrophosphatases in cartilage extracts.
Mutations in the ANKHgene described in both familial and sporadic cases
increase elaboration and extracellular transport of pyrophosphate.
The increase in pyrophosphate production appears to be related to enhanced
activity of ATP pyrophosphohydrolase and 5'-nucleotidase, which catalyze the
reaction of ATP to adenosine and pyrophosphate.
pyrophosphate could combine with calcium to form CPPD crystals in
matrix vesicles or on collagen fibers.
There are decreased levels of cartilage glycosaminoglycans that normally
inhibit and regulate crystal nucleation.

PATOFISIOLOGI
Pyrophosphate is probably generated in abnormal cartilage
by enzyme activity at chondrocyte surfaces; it combines with
calcium ions in the matrix where crystal nucleation occurs on
collagen fibres. The crystals grow into microscopic tophi,
which appear as nests of amorphous material in the cartilage
matrix.
Chondrocalcinosis is most pronounced in fibrocartilaginous
structures (e.g. the menisci of the knee, triangular ligament of
the wrist, pubic symphysis and intervertebral discs) but may
also occur in hyaline articular cartilage, tendons and periarticular soft tissues. From time to time CPPD crystals are
extruded into the joint where they excite an inflammatory
reaction similar to gout. The longstanding presence of CPPD
crystals also appears to influence the development of
osteoarthritis in joints not usually prone to this condition (e.g.
shoulders, elbows and ankles). Characteristically, there is a
hypertrophic reaction with marked osteophyte formation.
Synovitis is more obvious than in ordinary osteoarthritis.

MANIFESTASI KLINIK
Chondrocalcinosis calcification of fibrocartilage or hyaline
cartilage. The incidence of chondrocalcinosis increases with
advancing age. Females >>>>. Fortunately, patients with
chondrocalcinosis are frequently asymptomatic.
Pseudogout The most common cause of acute monoarthritis
in the elderly. The acute attack mimics, but is less severe than,
gout, with rapid onset of severe joint pain, swelling, and
erythema. The knee,wrist,first metatarsophalangeal joint.
Acute pseudogout may occur spontaneously or may be
associated with an intercurrent illness, trauma, surgery
(particularly parathyroidectomy), or thyroxine replacement.
Chronic pyrophosphate arthropathy is more common in
females. The knees, wrists, shoulders, elbows, hips, and hands
are frequently affected. Symptoms include early morning
stiffness, and multiple joints are often involved. Affected joints
show swelling and limited motion. Synovitis is typically more
severe than with OA but less severe than with RA.

DIAGNOSIS
X-rays
The characteristic x-ray features arise from a combination of
(1) intra-articular and peri-articular calcification, and (2)
degenerative arthritis in distinctive sites
The diagnosis of CPPD can be confirmed by demonstration of
the weakly positive, birefringent, rhomboid-shaped calcium
pyrophosphate crystals associated with typical symptoms. The
synovial fluid white count is usually around 20,000/mm 3

PX. LAB
pemeriksaan darah tidak ada yang spesifik
laju endap darah meninggi selama fase akut
leukosit PMN sedikit meninggi.
Sekitar 20% hiperurisemia ,5% disertai kristal MSU.
mikroskop cahaya biasa : bentuk kristal seperti kubus
(Rhomboid), atau batang pendek bersifat birefringece positif
lemah(mikroskop polarisasi cahaya). Pada keadaan lain dapat
berbentuk jarum seperti kristal MSU.

TREATMENT
The treatment of pseudogout is the same as that of
acute gout: rest and high-dosage anti-inflammatory
therapy. In elderly patients, joint aspiration and intraarticular corticosteroid injection is the treatment of
choice as these patients are more vulnerable to the side
effects of non-steroidal anti-inflammatory drugs.
Kortikosteroid injeksi 40-80 mg
NSAIDs ( fenilbutazon 400-600mg/hr atau indometasin
75-150mg/hr)
oraL cholchine utk pencegahan
Evakuasi kristal untuk mengurangi inflamasi pada
pseudogout akut dan crytal induced arthritis yang
lain. (IPD)

REFERENSI
1. Solomon ,louis dkk. Appleys System of
Orthopaedics and
Fractures 9th edition. The
British Library ; London : 2010.
2. Toy , Rosenbaum dkk. Case Files Orthopaedic
Surgery. Lange McGraw-Hill education,LLC; United
States: 2013.
3. Fauci, Braunwald dkk. Harrisons principles of
Internal Medicine 17th edition. McGraw-Hills;
USA: 2008.