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Critical Crystals- A Case of Crystal Arthropathy Leading to ICU Admission
Description
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A3400 - Critical Crystals- A Case of Crystal Arthropathy Leading to ICU Admission
Author Block: C. Shappell, L. M. Kimmig; Medicine, University of Chicago, Chicago, IL, United States.
Introduction:
Gout and calcium pyrophosphate crystal disease (CPPD) are known for causing episodes of severe acute inflammation and long-term joint disability. However to our knowledge, crystal deposition disease (CDD) has not previously been reported as a cause of critical illness.
Case report:
A 55-year-old man with history of CLL in remission, hypertension, and well-controlled T2DM presented to an outside hospital with neck and right arm pain, weakness of the right arm, and fever. He was admitted, started on antibiotics and underwent lumbar puncture on hospital day (HD) 1 with normal studies. Blood and CSF cultures were negative. MRI of the spine reportedly demonstrated signs of osteomyelitis and diskitis at C2-C3. He was transferred to a tertiary care center on HD 3.
After transfer he complained of worsening neck and arm pain despite >48 hours of antibiotics. He remained febrile (Tmax 39.4 degrees Celsius) and ill-appearing. Labs were notable for leukocytosis, CRP of 306 mg/L, and ESR 109 mm/hr. Broad spectrum antibiotics were continued. The patient developed worsening pain on HD 3-5 and CRP and ESR rose to 392 mg/L and 116 mm/Hr respectively. Plain films and duplex ultrasonography of the right arm were unrevealing. Transthoracic echocardiography was negative for vegetations. The patient was ultimately transferred to the ICU after developing atrial fibrillation with rapid ventricular response. A repeat MRI of the spine demonstrated a C2-C3 paravertebral process with erosions and asymmetric intense signal in the C2-C3 disc, consistent with gout. There was no definitive spondylodiscitis seen. Negatively and positively birefringent crystals were present in the wrist arthrocentesis fluid.
The patient was started on glucocorticoid and NSAID therapy with prompt improvement in his pain and defervescence. CRP and ESR prior to discharge. Antibiotics were continued.
Discussion:
Axial involvement in crystal arthropathies is rare but well described and can mimic spondylodiscitis or epidural abscess. Both gout and CPPD are highly inflammatory states that can lead to elevation of acute-phase reactants but are not commonly associated with admission to an intensive care unit. While our patient had complicating features (e.g. atrial fibrillation), he presented with a profound inflammatory state and ill appearance. Not all inflammation encountered in the ICU is sepsis and axial crystal arthropathies should be on the differential for patients with presumed vertebral osteomyelitis that does not improve with therapy.
Author Block: C. Shappell, L. M. Kimmig; Medicine, University of Chicago, Chicago, IL, United States.
Introduction:
Gout and calcium pyrophosphate crystal disease (CPPD) are known for causing episodes of severe acute inflammation and long-term joint disability. However to our knowledge, crystal deposition disease (CDD) has not previously been reported as a cause of critical illness.
Case report:
A 55-year-old man with history of CLL in remission, hypertension, and well-controlled T2DM presented to an outside hospital with neck and right arm pain, weakness of the right arm, and fever. He was admitted, started on antibiotics and underwent lumbar puncture on hospital day (HD) 1 with normal studies. Blood and CSF cultures were negative. MRI of the spine reportedly demonstrated signs of osteomyelitis and diskitis at C2-C3. He was transferred to a tertiary care center on HD 3.
After transfer he complained of worsening neck and arm pain despite >48 hours of antibiotics. He remained febrile (Tmax 39.4 degrees Celsius) and ill-appearing. Labs were notable for leukocytosis, CRP of 306 mg/L, and ESR 109 mm/hr. Broad spectrum antibiotics were continued. The patient developed worsening pain on HD 3-5 and CRP and ESR rose to 392 mg/L and 116 mm/Hr respectively. Plain films and duplex ultrasonography of the right arm were unrevealing. Transthoracic echocardiography was negative for vegetations. The patient was ultimately transferred to the ICU after developing atrial fibrillation with rapid ventricular response. A repeat MRI of the spine demonstrated a C2-C3 paravertebral process with erosions and asymmetric intense signal in the C2-C3 disc, consistent with gout. There was no definitive spondylodiscitis seen. Negatively and positively birefringent crystals were present in the wrist arthrocentesis fluid.
The patient was started on glucocorticoid and NSAID therapy with prompt improvement in his pain and defervescence. CRP and ESR prior to discharge. Antibiotics were continued.
Discussion:
Axial involvement in crystal arthropathies is rare but well described and can mimic spondylodiscitis or epidural abscess. Both gout and CPPD are highly inflammatory states that can lead to elevation of acute-phase reactants but are not commonly associated with admission to an intensive care unit. While our patient had complicating features (e.g. atrial fibrillation), he presented with a profound inflammatory state and ill appearance. Not all inflammation encountered in the ICU is sepsis and axial crystal arthropathies should be on the differential for patients with presumed vertebral osteomyelitis that does not improve with therapy.
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