Recurrent acute inflammation associated with focal apatite crystal deposition

Abstract

SYNDROME OF RECURRENT painful periarticular lesions associated with roentgenographically demonstrable calcification was recently described by Pinals and Short.' These authors suggested ( a ) that a fundamental defect in connective tissue exists in these individuals, and ( b ) that the inflammation observed was mediated by the preformed ectopic mineral phase. The purpose of this paper is to report three additional patients with a similar clinical course and to describe limited pathologic and crystallographic findings in typical lesions.Patient #l. C. O., a 67-year-old white woman of Italian descent was admitted to Hahnemann Hospital on 9/21/64 because of pain in the left knee. Although an ill-defined, intermittent, transient aching had been present for 5 weeks, severe pain was first noted on 9/19/64 during attempted weight bearing after arising from bed in the morning. Tenderness, warmth and cutaneous erythema were localized to the lateral aspect of the left knee. Mild tenderness was also elicited in the right wrist and in the ankle and subtalar joints bilaterally. The oral temperature was 99.4 F.Previous attacks of acute inflammation had occurred intermittently over a period ot approximately 30 years; 3 attacks of "bursitis" were described, once in the right and twice in the left shoulder. The proximal tarsal area was unilaterally involved on one occasion. The lateral aspect of each knee previously had been acutely symptomatic. Except for intermittent mild morning stiffness in the wrists, no musculoskeletal symptoms were noted between attacks. Moderate diastolic hypertension had been present for 5 years and thyroid had been prescribed for hypothyroidism diagnosed clinically by her family physician 3 years before. Soft tissue calcifications were visualized roentgenographically in the capsule of the left shoulder and in the lateral collateral ligaments of both knees ( Fig. la-b). Laboratory findings are listed in Table 1.A provisional diagnosis of gouty arthritis was made by the admitting resident. Colchicine therapy, 0.5 mg. every hour for 10 hours, resulted in moderate relief of pain and subsidence of warmth and erythema. Marked tenderness over the lateral collateral ligament of the knee persisted; 0.5 ml. of clear, viscous fluid was removed by needle aspiration of the left knee joint. Microscopically, no crystals were visualized in a wet smear by phase-polarized light.z Aspiration of a small fluctuant mass at the site of maximum tenderness yielded 0.5 ml. of thick, white liquid; 40 mg. of triamcinolone diacetate were injected through the same needle. Microscopic examination of a "wet smear" revealed innumerable globular bodies varying from 3 to 65 p in diameter (Fig. 2a). These "shiny coin" bodies

Chalky joint effusion

“…The present report differs from these studies in two respects: first, the amount of crystals in the synovial fluid was extremely large, giving it a unique chalky white appearance, and second, indisputable evidence that the synovial fluid particles represented crystals of the apatite series was provided by the X-ray diffraction analysis. The globular concentric laminated bodies observed by phase microscopy of the synovial fluid in the present case (Figure 3b) are similar to, though tending to be somewhat smaller than, those observed in exudates proved to contain hydroxyapatite from patients with acute periarticular inflammation (9).…”

“…Hydroxyapatite crystals have previously been identified in bursa1 and peritendinous exudates of patients with calcific tendinitis and periarthritis (9). In addition, solitary deposits of hydroxyapatite have been found in menisci from knees of 1.4% of cadavers (10).…”

Destructive Spondylarthropathy in Hemodialyzed Patients

“…Hydroxyapatite crystals were identified in the disc matrix we studied by TEM, and apatite deposition disease is a common occurrence in dialysis patients. Periarticular calcifications, which are known to contain apatite crystals (1, [17][18][19], are frequently observed among patients on long-term hemodialysis (1, [20][21][22]. They affect the shoulders, hips, wrists, or interphalangeal joints, and appear on radiographs as small radiodensities located in tendons, ligaments, or capsulae.…”

Hydroxyapatite deposition in osteoarthritic articular cartilage of the proximal femoral head

“…Hydroxyapatite crystals have been found recently in the synovial fluid of patients with osteoarthritis (OA) (1)(2)(3)(4)(5). It has been suggested that these crystals play a role in the onset of OA (6), in the inflammation (1,(7)(8)(9)(10)(11)(12), or in the progression of joint destruction (2,3,13,14).…”