Synovium to Myocardium: A Case of Calcium Pyrophosphate Dihydrate Crystal Arthritis Associated With Myocardial Infarction

Abstract

Both gout and pseudogout are crystal-induced arthropathies. Here, we report a case of acute calcium pyrophosphate dihydrate (CPPD) arthritis associated with type 1 myocardial infarction (MI). An 83-year-old female presented to our emergency department with generalized weakness and bilateral lower extremity edema. Her left foot was noted to be more inflamed compared to the right, with cardinal signs of pain, swelling, erythema, and warmth. A presumptive diagnosis of cellulitis was made, and antibiotics were initiated. Further investigations revealed elevated troponins with new-onset bundle branch block, ST, and T-wave changes on electrocardiogram, indicating a type 1 MI. After a review of the patient's history, imaging of the extremity, elevated inflammatory markers, and the typical distribution and pattern of inflammation, the diagnosis was changed to pseudogout. Steroids and colchicine were initiated, providing instant relief. This case highlights a possible association between cardiovascular disease and pseudogout, emphasizing the need for further studies regarding this relationship. Despite being rare, physicians should be made aware of this relationship, especially in patients with a history of CPPD arthritis presenting with type 1 MI.

Keywords: calcium pyrophosphate dihydrate crystal deposition; cppd arthritis; crystal arthropathy; myocardial infarction; pseudogout.

Figure 1. Lower extremity physical findings.

Figure 2. Electrocardiogram in sinus rhythm with left anterior fascicular block and non-specific ST and T-wave abnormality.

Figure 3. X-rays of the left foot (A) and left ankle (B) showing a metallic plate with screws along the distal diaphysis of the third metatarsal bone (green arrow), a small calcaneal spur (red arrow), some osteopenia, degenerative changes in tarsal metatarsal joints, and soft-tissue swelling.

Figure 4. Electrocardiogram in sinus rhythm, with left anterior fascicular block and lateral ST-segment depressions.

Figure 5. (A, B) Cardiac catheterization showing the left main coronary artery 20% occluded, left anterior descending ostium with 95% occlusion (green arrow), right-to-left collateralization, circumflex artery with diffuse mild stenosis, and right coronary artery 50% occluded at the ostium.