Pseudogout (CPPD) in the Knee: Presentation and Treatment

Clinical Presentation

The American College of Rheumatology suggests that pseudogout in the knee typically presents as acute monoarticular arthritis with severe pain, swelling, warmth, and erythema, often mimicking septic arthritis or gout, with a high frequency of polyarticular involvement in elderly patients 1
Concurrent osteoarthritis is common, as CPPD frequently coexists with degenerative joint disease, affecting the knees and other large joints 2

The European League Against Rheumatism recommends that for acute pseudogout in the knee, intra-articular injection of long-acting glucocorticosteroids combined with joint aspiration is the optimal first-line treatment, with a strength of evidence rated as high 1
The American Geriatrics Society suggests performing joint aspiration first to confirm CPP crystals and exclude infection, followed by injection of triamcinolone acetonide or equivalent long-acting corticosteroid preparation, with a moderate strength of evidence 1, 3

The Osteoarthritis Research Society International recommends treating chronic CPPD with concurrent OA following evidence-based OA management guidelines, with special attention to the inflammatory component, using low-dose colchicine (0.5 mg twice daily) with a number needed to treat (NNT) of 2 for >30% pain reduction, and hydroxychloroquine with an NNT of 2 for clinical response 2
The American College of Rheumatology suggests avoiding high molecular weight hyaluronan intra-articular injections as they may induce acute attacks, with a high strength of evidence 2

The American Geriatrics Society recommends never using prolonged corticosteroid courses without a clear tapering plan, as this increases adverse effects without additional benefit, with a high strength of evidence 3
The European League Against Rheumatism suggests assessing cardiovascular, renal, and metabolic comorbidities before selecting any treatment, especially in elderly patients, with a moderate strength of evidence 3