Rheumatoid Arthritis, Gout, Pseudogout (CPPD) and Related Health Concerns

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

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Diagnosis and Early Detection: Difficult Problems

A true diagnosis of Rheumatoid Arthritis is often difficult and time consuming. If the General Practitioner diagnoses RA, the patient should insist on a visit to a rheumatologist. Rheumatoid Arthritis is diagnosed with a combination of laboratory tests and assessment of symptoms and signs of the disease. The clinical history is by far the most important diagnostic tool, and laboratory tests should be used to support the diagnosis, as the laboratory and radiological findings may often be unclear or nonspecific. A skilled physical examination should confirm swelling and inflammation of the joint synovium, and follow-up exams to objectively recognize the appropriate pattern of changes with exam, assessment and repeat testing is important to an accurate diagnosis. The patient may be denied the most effective treatment if the diagnosis is incorrect. A differential diagnosis should be performed before or concurrently with the testing for Rheumatoid Arthritis, since the tests for RA are often unclear. Ruling out conditions that are less severe than RA seems a sensible first step. Common diagnostic workup for gout and pseudogout (calcium pyrophosphate deposition) includes a needle aspiration of synovial fluid from the affected joint, with a microscopic look for calcium pyrophosphate crystals, followed by an X-ray of the joint to see if these crystals may be accumulating in the cartilage.

Laboratory tests include ethrocyte sedimentation rate (ESR), antinuclear antibody (ANA), rheumatoid factor (RF), anticyclic citrullinated peptide (anti-CCP), and C-reactive protein (CRP), as well as x-ray, ultrasonography, and MRI. All of these tests could be negative or unclear in early stages of the disease, and a true diagnosis is only clear when positive test results are confirmed with a physical assessment. Only about 40 percent of RA patients with a clear diagnosis test positive for ANA, and false-positives are noted in RA as well, as 5% of the healthy population will test positive. About 20 percent of patients with Rheumatoid Arthritis will have a negative RF, as well. Rheumatoid factor is an IgG antibody associated with an autoimmune reaction against normal joint tissue. ESR is a non-specific test for the rate of red blood cells that precipitate in a period of one hour, and indicates a higher than normal rate of inflammatory reaction. ESR is affected by the amount of fibrinogen in the body, which is a pro-sedimentation factor, and this could be affected by the amount of advanced glycation endproducts in the body, which is an important subject that you may read about further along in this article. Anti-CCP (ACCP), a test for autoantibodies to protein fragments that may be associated with RA has a sensitivity rating similar to RF, and CRP positives may indicate a wide variety of inflammatory disorders. A sound diagnosis depends upon more than just one of these tests being positive or negative.

A more recent laboratory development is the anti-citrullinated antibody (ACPA) test. ACPA are autoantibodies that are formed as the body creates an inflammatory reaction to normal proteins, specifically protein fragments or altered proteins of the amino acid arginine. Citrulinated vimentin is one of these autoantigens noted in RA, and is secreted by immune cytokines such as tumor-necrosis factor (TNFalpha). Newer ELISA tests utilize ACPA with a genetically modified citrullinated vimentin (MCV) to optimize the performance of the test. These tests have been shown to diagnose patients with RA when the anti-CCP test is negative, and the ACPA tests are considered more specific than RF. These types of newer tests also give the patient and physician a better idea of the specific underlying causes of the RA, which could significantly benefit a research-oriented Complementary Medicine physician.

The American Academy of Rheumatology criteria for the diagnosis of Rheumatoid Arthritis requires that 4 of 7 key criteria be present. These 7 important criteria include:

  1. morning stiffness in an around joints lasting more than 1 hour, and relieved by range of motion or simple activity
  2. simultaneous signs of arthritis in 3 or more joint areas, typically the middle joints of the index and middle finger, as well as the wrist, but also seen in various small joints in the body, especially the elbows, shoulders, knees, ankles, and feet. The upper cervical spine is often affected in later stages of the disease, and swelling and pain in the distal finger joints is generally not seen.
  3. arthritis noted in at least one area in a wrist, metacarpal or proximal interphalangeal joint of the hand or finger, which is the most typical areas of advanced symptoms
  4. symmetrical arthritis involving the same joint areas on both sides of the body
  5. rheumatoid nodules: firm, non-tender, subcutaneous nodules commonly found at the elbow, back of the forearm, or metacarpophalangeal joint at the base of the finger; seen in about 25% of RA cases
  6. positive rheumatoid factor (RF) in blood tests
  7. radiological changes typical of RA on hand and wrist x-rays

Obviously, the diagnosis of Rheumatoid Arthritis is not simple, especially in early stages, and meeting 4 of these 7 criteria may mean that you are in a later stage of the disease. The intelligent patient will take a pro-active approach when a diagnosis of RA is pursued. Instead of assuming that the diagnosis is correct with minimal testing and no actual diagnosis by a rheumatologist, the intelligent patient will insist on the correct testing and assessment, and also seek objective information on these tests and what they may reveal as to the underlying mechanisms of the disease. Standard medicine still has little to offer for treatment of Rheumatoid Arthritis, and there is a tendency to not fully explore diagnostic testing, which is often difficult and time consuming, and instead just prescribe the standard therapy, which is a sort of one-size-fits-all approach. Newer tests will differentiate underlying mechansisms and may present the Complementary Medicine physician with diagnostic data that can be applied to recent research and specific herbal chemicals, nutritional medicine, and even acupuncture research and approach. Newer anti-rheumatic drugs come with significant side effects and many patients are unable to tolerate current drug therapies, while others do not respond to these drugs, or have an initial response that diminishes over time. Complementary Medicine may help treat these side effects and potentially aid these therapies as well.

Since diagnosis may be unclear, considerations of differential diagnosis, or other possible diagnoses, is important. Since RA is part of a category of multi-joint inflammatory diseases, it may be mistaken for other arthritic diseases in this classification, especially Lupus, Polymyositis-Dermatomyositis, Psoriatic arthritis, Sjogren's syndrome, Scleroderma, Palindromic Rheumatism, and Reactive arthritis, especially if the disease is in early stages. Viral joint disease is also a possibility, such as hepatitis C small-joint polyarthritis, which is very similar to RA. Gout, pseudogout (CPPD), Lyme disease, sarcoidosis, amyloidosis, Whipple's disease, gonococcal arthritis, ankylosing spondylitis spreading to small joints, and hemochromatosis are all considerations in differential diagnosis, as is fibromyalgia. Many cases of early stage osteoarthritis are also mistakenly diagnosed as Rheumatoid Arthritis, and acute rheumatic fever with joint pain and swelling may be mistaken for RA as well. The patient should make sure that the diagnosis is correct. The key to this process is making sure that a respected rheumatoid disease specialist makes an exam, assessment, orders the proper tests, and follows up over time if this is needed. Simply accepting a diagnosis from a Medical Doctor that is not a rheumatic disease specialist, and starting the harsh course of medications, is not advisable. Starting treatment early with a TCM physician is sensible, as the array of treatments offered in this holistic specialty is not completely dependent on the specificity of the disease, and early intervention may prevent the progression of the disease.

In 2013, the medical community is finally taking the subject of correct and early accurate diagnosis of Rheumatoid Arthritis and other rheumatic joint diseases seriously. This is because a realization is dawning the early intervention and prevention may be the key to successful disease management. Finally, early signs and symptoms are an important consideration for patients seeking to prevent the disease, or stop it before it proceeds to a stage of long duration. Symptoms that often precede the classic morning stiffness and joint swelling include fatique, malaise, depression, and low-grade fever. Fatique often occurs about 4-6 hours after waking. Early treatment and reversal of the disease is the key to a successful outcome. Slowing the complex mechanisms of RA in early stages may result in a short course of classic symptoms, and give the patient the time to improve systemic health and correct the underlying causes of the disease. Waiting until the joint swelling and deformity becomes severe and degenerates the cartilage is not sensible. Early treatment, preventative measures, and treatment that addresses complex underlying mechanisms is the realm of Integrative and Complementary Medicine.

Diagnosis of Gout and Pseudogout - new Techniques for Improved Treatment Protocol

Gout and Pseudogout, often now called Calcium Pyrophosphate Crystal Deposition (CPPD), or deposition of other conjugated mineral ions, has not been accurately diagnosed in the past. In 2015, experts at the University Paris Diderot division of Rheumatology explored the potential for advanced ultrasonograpy to more easily and accurately diagnose these conditions. An initial randomized controlled study evaluated 25 consecutive patients diagnosed with CPPD in knee cartilage, matching them with 25 similar patients without CPPD. Standard X-ray tests and modern ultrasonography were used to diagnose these patients, with 2 rheumatologists blinded to the diagnoses, one using standard X-ray and the other ultrasonography. Ultrasonography identified 100 percent of the patients with CPPD in the knee, whereas X-ray testing only identified 64 percent. A higher accuracy in such testing would save many patients from receiving the wrong therapy (PMID: 26077407). Diagnosis of gout and pseudogout, or CPPD, in the knee joint has often not even been considered until recently. To see if this is a prevalent condition, experts at the Nihon University School of Medicine, in 2014, examined over 600 cadavers, both male and female, to judge the prevalence of CPPD in knee cartilage. The findings showed that CPPD in the knee was seen in 13 percent of the population, and was correlated with aging, gender, and the severity of cartilage degeneration. This study shows that many cases of joint degeneration could be slowed or reversed with appropriate treatment, rather than just waiting until a prosthetic can be installed (PMID: 24814686).

Differentiating gout and Pseudogout, or CPPD, has been a problem as well. A 2015 study at the University of Mannheim, and the University of Leipzig, in Germany, showed that ultrasonograpy alone was not sufficient to differentiate these 2 types of arthroses. It was suggested that uric acid levels and Doppler studies of hypervascularization should be routinely used as well (PMID: 25399385). Analysis of synovial fluid has also been used to detect calcium pyrophosphate crystals.