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Calcium Pyrophosphate Deposition Disease (CPPD) and Pseudogout

Overview

  • Calcium pyrophosphate deposition disease (CPPD), also known as pseudogout.
  • **Clinical Features: **
    • Asymmetric, inflammatory, pauciarticular arthritis.
    • Most frequently involves the knee, wrist, or first metatarsophalangeal joint.

Inflammatory Symptoms

  • Symptoms include:
    • Erythema (redness of the skin).
    • Warmth (increased temperature of the joint).
    • Swelling (edema).
    • Tenderness (pain when pressure is applied).

Radiographic Findings

  • Chondrocalcinosis: calcification of the cartilage; hallmark of CPPD.
  • Imaging Confirmation: Polarized microscopy of joint fluid can confirm CPPD disease by showing positively birefringent crystals, in contrast to gout which is confirmed by negatively birefringent crystals.

Gout vs. Osteoarthritis

  • Gout:
    • Typically affects the first metatarsophalangeal joint (podagra).
    • X-ray findings include punched-out erosions.
  • Osteoarthritis: non-inflammatory in nature and typically presents as chronic mechanical pain.
  • Psoriatic Arthritis: characterized by psoriasis, nail changes, dactylitis, and involvement of multiple joints.

Septic Arthritis

  • Characteristics: Fever, systemic illness, positive gram stain or high suspicion based on clinical findings.

Acute Monoarthritis

  • Clinical Presentation: Acute monoarthritis, with a sudden painful, swollen knee over 2-3 days; knee is the most common joint affected in pseudogout.

Additional Clinical Considerations

  • History of similar prior attacks is often present in CPPD patients.
  • Age Factor: More common in older adults greater than 60-65 years old.

Lymphadenopathy Discovery

General Characteristics

  • Self-limiting with a benign etiology typically.
  • Abnormal lymphadenopathy:
    • Locations: supraclavicular, popliteal, and iliac; epitrochlear nodes greater than 5 mm in diameter are considered abnormal.
  • Supraclavicular lymphadenopathy: high risk for intra-abdominal malignancy, particularly in patients over the age of 40.

Infection and Other Causes

  • Infection commonly causes anterior cervical, posterior cervical, submental, and submandibular lymphadenopathy.
  • Axillary lymphadenopathy: linked to infections or injuries of the upper extremities.
  • Healthy adults may present with inguinal lymphadenopathy.
  • Surviving adults above the age of 40 have the highest malignancy-related risks associated with supraclavicular lymph nodes.

Malignant Associations

  • Supraclavicular lymph nodes drain lymph from thorax and abdomen and enlargement may indicate metastatic disease. Malignancies can include:
    • Lung cancer
    • Gastric cancer
    • Esophageal cancer
    • Pancreatic cancer
    • Lymphoma
    • Breast cancer
  • Virchow's Node: Left supraclavicular node often associated with gastric carcinoma.

Reactive Conditions

  • Anterior cervical nodes: commonly reactive due to upper respiratory infections or pharyngitis.
  • Posterior cervical nodes: more related to viral infections like EBV and CMV.
  • Axillary nodes: can be reactive due to infection, trauma to arm, or breast pathology.
  • Inguinal nodes: associated with infections of the lower extremities or genital area; often benign.

Chronic Cough in Adults and Children

Adult Considerations

  • Four Most Common Causes:
    1. Upper airway cough syndrome
    2. Asthma
    3. Nonasthmatic eosinophilic bronchitis
    4. Reflux-related disorders
  • Upper airway cough syndrome: most common cause of chronic cough in adults, particularly in non-smokers with a normal chest x-ray.
    • Symptoms: nasal stuffiness, sneezing, postnasal drainage (contributing factors include allergic/non-allergic rhinitis, chronic sinusitis).
    • Symptoms may include throat clearing, cough worsening at night, and cobblestoning of the posterior pharynx.

Pediatric Considerations

  • Top 3 Causes of Chronic Cough in Children (6-14 years):
    1. Asthma
    2. Protracted bacterial bronchitis
    3. Upper airway cough syndrome

Infectious Diseases and their Implications

Yersinia pestis

  • Characteristic: An aerobic fermentative gram-negative rod.
  • Transmission: Via flea bites or aerosols from pulmonary plague; zoonotic infection with humans as accidental hosts.
  • Geographical prevalence includes regions in the southwestern United States.

Escherichia coli

  • Generally causes gastroenteritis, urinary tract infections, and meningitis.

Listeria monocytogenes

  • A gram-positive rod leading to influenza-like illness; often linked to contaminated food products.

Coxiella burnetti

  • Affects animals but can cause Q fever in humans through animal contact.

Brucella melitensis

  • A gram-negative coccobacillus causing brucellosis; human exposure from infected livestock products.

Infectious Risk Factors

  • Common infectious presentations suggestive of exposure include pneumonias, or pulmonary plague from rodent or flea interactions.

Acute Bronchitis

  • Acute bronchitis: Essentially viral infections account for 90-99% of cases with some atypical organisms like Mycoplasma pneumoniae and Chlamydia pneumoniae found in less than 1% of cases.
  • Symptoms: Cough without significant fever, minimal systemic symptoms, often viral in etiology.
  • Treatment: Focused on symptomatic relief since antibiotics are generally not indicated for uncomplicated acute bronchitis.

Vocal Cord Dysfunction and Other Respiratory Conditions

Vocal Cord Dysfunction

  • Presenting as extreme dyspnea with inspiratory stridor/wheezing, often mistaken for asthma.
  • Common Symptoms: Normal O2 saturation, minimal respiratory distress, poor bronchodilator response.
  • Typically found in women aged 30-40.

Exercise-Induced Asthma

  • Characterized by expiratory wheezing.
  • Relief achieved with albuterol inhalers.

Differentiating Conditions in Athletic Presentations

  • Laryngeal Edema: Associated with allergies, trauma, and significant respiratory distress.
  • Anaphylaxis: Defined by urticaria, airway swelling, hypotension.
  • Cervical Spine Injuries: Protocol for management includes immobilization and transport to medical services, particularly for athletes with bilateral neurological symptoms.

Capacity to Make Medical Decisions

Definition and Components
  • Medical Decision-Making Capacity: The ability of a patient to understand the benefits, risks, and alternatives to a given treatment or the option of no treatment. Components include:
    • Demonstration of appreciation of information.
    • Reasoning capability in decisions.
    • Communication of a choice.
Lack of Capacity
  • Potential need for surrogate decision-makers or consideration of living wills, especially relevant in cases of impaired capacity.

Cancer Screening and Diagnostic Procedures

Liver Disease Surveillance

  • Cirrhosis poses a higher risk for hepatocellular carcinoma (HCC); surveillance recommended through ultrasonography every 6 months.
  • Serum alpha fetoprotein levels may also guide assessment, depending on guidelines.

Pleural Effusion Assessment

  • Light's Criteria: Used to distinguish between transudative and exudative pleural effusions.
    • Exudative if pleural fluid protein to serum protein ratio > 0.5 or if pleural LDH to serum LDH ratio > 0.6 or if pleural LDH > 2/3 the upper limit of normal for serum.
  • Blood glucose levels in pleural fluid can suggest malignancy or infections such as tuberculosis.

Hormonal and Metabolic Disorders

Endocrine Disorders Due to Opioid Use

  • Chronic opioid therapy can suppress the hypothalamic-pituitary-gonadal axis, leading to opioid-induced androgen deficiency characterized by symptoms such as fatigue, low libido, and depression.

Metabolic Health in Women with PCOS

  • Involves a risk for endometrial carcinoma linked with anovulation and unopposed estrogen exposure.

Managing Osteoporosis and Bone Health

  • Recommended treatment protocols involve bisphosphonates and surveillance methods based on bone density examinations and fracture risk stratification like the FRAX score.

Conclusion

These detailed notes provide a comprehensive overview of the conditions and diagnostic criteria discussed across various medical topics. Each section clarifies the defining features, etiologies, risk factors, clinical presentations, and management strategies pertinent to diverse medical concerns, offering students an in-depth understanding critical for exams and clinical settings.