Gilda Clayburne

Clinical Diagnostic Criteria for Gout: Comparsion With the Gold Standard of Synovial Fluid Crystal Analysis

Background:Several classification or diagnostic criteria sets for gout have been proposed but none validated. Objective:This small pilot study considered urate crystal identification as the gold standard for diagnosis and compared the clinical aspects of 3 proposed criteria sets with that standard. Methods:Eighty-two subjects who had synovial fluid analyses in a VA medical center were studied. ARA (ACR), Rome, and New York clinical criteria sets and individual criteria were recorded in the 30 patients who had urate crystals versus the remainder with no urate crystals. Results:Presence of 2 of 3 Rome clinical criteria had the highest positive predictive value at 76.9%. None of the 3 studied criteria sets were more than 70% sensitive or 88.5% specific. The clinical features of the ARA (ACR) preliminary classification criteria had 70% sensitivity and 78.8% specificity. Conclusions:The various proposed clinical criteria can provide support for a diagnosis or exclusion of gout, but unless improved criteria can be developed crystal identification should remain the gold standard.

Processing of noninflammatory synovial fluids with hyaluronidase for cytospin preparations improves the accuracy of differential counts.

Differential leukocyte counts on noninflammatory synovial fluids (NISF) are not widely reported or used in research, apparently due to technical difficulties related to either high viscosity or low numbers of cells. We describe an evaluation of a technique using hyaluronidase and cytospin preparations to study NISF. Twenty‐three consecutive synovial fluids (SF) with less than 2,000 white blood cells (WBC)/mm3 were studied either by the usual smear of a single drop or by adding two drops of hyaluronidase (150 USP units/ml) to 0.25 cc of SF and cytocentrifuging at 800 rpm for 10 min. Both preparations were stained with Wrights stain.

Idiopathic destructive arthropathies: clinical, light, and electron microscopic studies.

Rapidly destructive arthritis with relatively noninflammatory joint fluids has been described at shoulders as well as at other large joints under a variety of names in older persons. Because this syndrome frequently is not recognized, we have reviewed our experience with such cases. After excluding patients with known causes such as avascular necrosis, Pagets disease, neuropathic arthropathy, endocrine disorders, radiographic evidence of chondrocalcinosis, and hemodialysis, we have seen 20 such patients who are described in this report. All were over age 67, and 16 were women. Seventeen patients had shoulders involved; 6 had destructive arthritis at the knees. Many other patients had multiple sites affected. Six patients also had erosive osteoarthritis of small joints.All patients had diffuse cartilage loss and juxta-articular bone destruction. Patients had been symptomatic a mean of 3.5 years at the time of the study. Bony sclerosis on x-ray was more common than reported in previous series. Joint effusions were bloody or clear. All fluids had strongly positive alizarin red S positive chunks; apatites were confirmed in all 7 studied by electron microscopy. Nine had calcium pyrophosphate dihydrate crystals. The latter were somewhat more commonly associated with bony sclerosis, but crystal types did not explain all differences seen in x-ray patterns.Destructive arthropathy of the elderly involves many large joints in addition to the shoulders, and some patients also have erosive osteoarthritis of fingers. Although calcium pyrophosphate dihydrate crystals were present in many patients along with apatites, the role of crystals is not clear. Radiographic patterns may be more diverse than previously suggested by some researchers, so that the spectrum of idiopathic destructive arthritis reported may depend on selection criteria. It is important to be aware of this noninfectious cause of severe joint destruction at a variety of joints.

Synovial xanthomatosis: are there clues to mechanisms for this rare disease?

We report a 64-year-old man with arthritis and nodules to describe that this picture can be caused by normo-lipidemic xanthomas. Light and electron microscopy (EM) plus polymerase chain reaction (PCR) studies were performed for diagnosis and investigation. These showed features typical of xanthomas plus PCR and EM evidence of possible infection with Chlamydia pneumoniae as a pathogenetic mechanism deserving consideration. With such rare diseases, any clues to possible mechanisms seem important to record and thus to encourage future investigations. This uncommon cause of arthritis and nodules had been confused with rheumatoid arthritis by others in this case.

Synovial fluid findings in a patient after hylan GF 20 injection.

An 80-year-old man with a long-standing history of generalized osteoarthritis was first seen in Rheumatology clinic in 2004. He had multiple depot corticosteroid injections of both shoulders and the left (L) knee as well as a series of 3 hylan GF 20 hyaluronic acid injections in his L knee from July to August 2004, with good pain relief. However, in July 2006, after the 1st injection of a second round of hylan in his L knee, he described pain in his knee for 3 days and slight swelling of his knee without frank heat or swelling. He was given a second injection and reported no pain or swelling. However, upon return for the final injection, the knee was noted to be warm and swollen. Results of knee aspiration (performed 1 week after the 2nd injection) confirmed an inflammatory response with 8400 WBC. He was then injected with the last of the hylan injections along with intra-articular depot corticosteroid. He did well until December 2006. At this time, he was given a course of low-molecular weight hyaluronic acid injections and did well until September 2007. A synovial fluid after the 2nd injection in this course was clear with rare WBC. The joint fluid with 8400 WBC obtained 1 week after hylan injection was centrifuged, and cells were fixed in glutaraldehyde and processed for electron microscopy, which is shown in the figures (Figs. 1 and 2). There were no crystals. Aggregates of amorphous and strand-like material (arrows) not seen in other osteoarthritis fluids were seen phagocytosed by and adjacent to mononuclear cells. These unique findings suggest that hylan material persisted in the joint fluid for the 1 week and might have contributed to the leukocyte response seen.