Working Diagnosis:
Acute Calcium Pyrophosphate Crystal Deposition Flare

Treatment:
On the third day of hospitalization, he developed acute onset of left wrist pain and swelling. He underwent an additional infectious work-up and his antibiotic coverage was broadened. Intravenous steroids were discontinued after concern for steroid-induced psychosis.

On hospital day nine, he had another acute exacerbation of bilateral wrist pain that improved with colchicine treatment. He was transitioned to naproxen for the remainder of his hospitalization.

Outcome:
He subsequently spent 23 days at a subacute rehabilitation facility. He continued to improve, and eventually returned home. He still had occasional wrist pain that was managed by his primary care doctor.

Author's Comments:
Acute Calcium Pyrophosphate Crystal Deposition can present as Systemic Inflammatory Response Syndrome (SIRS) in the elderly and is important to keep on the differential when evaluating arthritis. This case was also unique as it demonstrated rare and severe disease progression affecting his second and third metacarpophalangeal joints of his right hand.

Editor's Comments:
Acute pseudogout flares are typically self-limited and most frequently involves the knees, then the wrists. Pseudogout is also referred to as calcium pyrophosphate deposition disease or CPPD. It is estimated to affect approximately 5% of the adult population and is more slightly more common in females than males (1.4:1). Synovial fluid analysis is the standard for diagnosis which is made by observing their deep blue, or basophilic crystals. These crystals have a rhomboid shape and are weak positive birefringence on polarized light microscopy. Currently, there are no disease-modifying treatment options. There is currently a lack of evidence-based treatment options for acute flares. Non-steroidal anti-inflammatory medications, intra-articular corticosteroid injections, systemic steroids, and occasionally high-dose colchicine are used as treatment. This condition may result in significant limiting pain, but is not fatal.

References:
1. Abhishek A, Doherty M. Update on calcium pyrophosphate deposition. Clin Exp Rheumatol. 2016;34(4 Suppl 98):32-38.

2. Stack J, McCarthy G. Calcium pyrophosphate deposition (CPPD) disease - Treatment options. Best Pract Res Clin Rheumatol. 2021;35(4):101720.

3. Yates KA, Yoshida K, Xu C, et al. Acute Calcium Pyrophosphate Crystal Arthritis Flare Rate and Risk Factors for Recurrence. J Rheumatol. 2020;47(8):1261-1266.

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