COMMENTARY

A Painful, Red Wrist: Crack the Case

Stephen Paget, MD

Disclosures

December 23, 2016

Sometimes a cigar is just a cigar
—Sigmund Freud

A 76-year-old man with no history of trauma presents with sudden onset of severe pain and swelling of the left wrist, along with redness and marked restriction of range of motion. He was seen by his primary care physician, who noted wrist calcifications on radiography and diagnosed pseudogout/calcium pyrophosphate deposition disease.

The patient was treated with a splint and eventually a hard cast, without improvement. He was then seen by a rheumatologist, who confirmed the diagnosis of pseudogout and treated the patient with a local injection of steroids, which resulted in only 3 days of improvement. The patient was also started on colchicine 0.6 mg twice a day.

Because of persistent inflammation, the patient was referred to an infectious disease specialist, who did a workup to rule out infection and eventually treated the patient with amoxicillin and clavulanic acid. Laboratory tests at that time showed a white blood cell count of 9902, a negative anti-cyclic citrullinated peptide result, uric acid level of 7.1, normal calcium and parathyroid hormone levels, erythrocyte sedimentation rate of 92 mm/h, and negative blood cultures and Lyme disease test result. CT of the wrist and hand showed extensive calcifications and cyst formation consistent with pseudogout.

Because of persistent left wrist inflammation, the patient was treated with three courses of prednisone, at an initial dose of 40 mg a day for 3 days and then tapered by 10 mg every 3 days to 0. There was mild improvement on the higher dose, but significant inflammation returned when the taper was completed.

The patient was then referred to an orthopedic surgeon, who performed arthroscopic surgery on the dorsal aspect of the left wrist where cultures were negative (while still on oral antibiotics). Multiple calcifications were found during surgery, and deposits was scraped away as much as possible. The operative report revealed inflammation, fragments of fibrous tissue, synovium, calcium deposits, and cartilage with chronic inflammation.

When the patient presented to me, he still had marked inflammation on the dorsal and volar aspects of the wrist, with marked restriction of range of motion, and inflammation involving the forearm and the dorsal aspect of the left hand to the metacarpophalangeal joints.

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