A Case of Acute Calcium Pyrophosphate Crystal Arthritis in the Lumbar Facet Joint

Sang Wan Chung; Jong Jin Yoo; Joon Woo Lee; You-Jung Ha; Eun Ha Kang; Yeong Wook Song; Yun Jong Lee

doi:10.4078/jrd.2016.23.2.125

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Chung, Yoo, Lee, Ha, Kang, Song, and Lee: A Case of Acute Calcium Pyrophosphate Crystal Arthritis in the Lumbar Facet Joint

Case Report

J Rheum Dis 2016;23(2):125-129.

Published online: 31 October 2016

DOI: https://doi.org/10.4078/jrd.2016.23.2.125

A Case of Acute Calcium Pyrophosphate Crystal Arthritis in the Lumbar Facet Joint

Sang Wan Chung¹, Jong Jin Yoo², Joon Woo Lee³, You-Jung Ha¹, Eun Ha Kang¹, Yeong Wook Song⁴, Yun Jong Lee^1,⁴

¹Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea

²Department of Internal Medicine, Kangdong Sacred Heart Hospital, Seoul, Korea

³Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea

⁴Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea

Corresponding to: Yun Jong Lee, Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro, 173 beon-gil, Bundang-gu, Seongnam 13620, Korea. E-mail: yn35@snu.ac.kr

Received 21 May 2015 Revised 29 June 2015 Accepted 30 June 2015

This is a Free Access article, which permits unrestricted non-commerical use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Calcium pyrophosphate dihydrate deposition disease most commonly presents with acute arthritis of the peripheral joints. Infrequently, a mass effect of this disease can cause axial symptoms, such as spinal stenosis, radiculopathy, or myelopathy. Herein, we report on the first Korean case of acute arthritis in the lumbar facet joint due to calcium pyrophosphate dihydrate crystal deposition disease. A 73-year-old female presented with acute fever, severe lumbago, and knee arthralgia, 11 days after partial parathyroidectomy. Plain radiographs showed multiple chondrocalcinosis, while a bone scan, computed tomography, and magnetic resonance imaging showed right L5-S1 facet arthritis. In synovial fluid from the facet and knee joints, positively birefringent calcium pyrophosphate dihydrate crystals were observed under polarized light microscopy. Under the diagnosis of acute calcium pyrophosphate dihydrate crystal arthritis (formerly known as ‘pseudogout’) in the facet joint, an intraarticular triamcinolone injection was administered, which resulted in dramatic improvement of the symptoms within 24 hours.

Keywords: Calcium pyrophosphate dihydrate deposition, Chondrocalcinosis, Zygapophyseal joint, Low back pain

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Figure 1.

Plain radiographs and bone scan. Radiographs show calcification (white arrows) in the intervertebral and foraminal spaces (A), pubic symphysis (B), and meniscus (C). (D) A technetium bone scan demonstrates increased radiotracer uptake in the right L5-S1 facet joint (black arrowhead).

Figure 2.

Lumbar spine computed tomography scans and magnetic resonance images. (A∼ C) Axial and sagittal computed tomography scans show calcification of the L5-S1 facet joint capsules, ligamentum flavum, and annulus fibrosus (asterisks). (D) Calcification around the facet joint is demonstrated as low signal intensity on a T1-weighted magnetic resonance image (white ar-rowhead). (E, F) T2-weighted and fat-suppressed imaging reveals facet joint effusion and bone marrow edema (white arrows).

Figure 3.

Compensated polarized light microscopy of a synovial fluid sample from the facet joint. Intracellular calcium pyrophosphate dihydrate crystals appear as rhomboids with positive birefringence (×200). The double headed arrows indicate the axis of the analyzer.

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