Schlapbach P, Pfluger D, Gerber N J
Rheumatologische Universitätsklinik, Inselspital, Bern.
Schweiz Med Wochenschr. 1992 Jun 20;122(25):969-74.
The diagnostic clarification of joint effusions of unknown origin is a challenge to every primary-care physician. Important diagnostic procedures are arthrocentesis and analysis of the aspirated synovial fluid. Synovial fluid analysis frequently allows differentiation between harmless effusions due to osteoarthritis and crystal induced inflammation, or the more devastating septic arthritis. 4475 synovial fluids were evaluated retrospectively to calculate the identification rate of crystals compatible with calcium pyrophosphate dihydrate (CPPD) and monosodium urate monohydrate (MSUM). 40.8% (1827) of synovial fluids were taken from females and 59.2% (2648) from males. The frequency of crystal identification varied considerably: 13.2% CPPD crystal identification in females, 10.9% in males; MSUM was identified in 1.5% of females, and in 10.9% of males. The spectrum of joint involvement was nearly identical in CPPD and MSUM positive synovial fluids. Exceptions were the higher frequency of CPPD identification in shoulder joints (CCPD:MSUM = 15.6:1), the higher frequency of MSUM identification in the ankle (MSUM:CPPD = 15.6:1) and the first metatarsophalangeal joints (MSUM:CPPD = 8:1). Clinical suspicion correlated well with crystal identification in MSUM positive samples (60%), but was poor in CPPD positive samples (36%). The poor correlation between clinical suspicion and crystal identification in CPPD positive synovial fluids is explicable by the less characteristic clinical presentation of pyrophosphate arthropathy in contrast to classical gout. A high percentage of crystal identification was found in joints or periarticular swellings in which aspiration is difficult and therefore rare (e.g. tendon sheaths, first metatarsophalangeal and first metacarpophalangeal joints), underlining the importance of synovial fluid aspiration despite the difficulty of arthrocentesis.
对不明原因的关节积液进行诊断性明确，是每位初级保健医生面临的一项挑战。重要的诊断程序是关节穿刺术及对抽取的滑液进行分析。滑液分析常常能够区分由骨关节炎和晶体诱发炎症导致的无害性积液，以及更具破坏性的化脓性关节炎。对4475份滑液进行回顾性评估，以计算与二水焦磷酸钙（CPPD）和一水尿酸钠（MSUM）相符的晶体识别率。40.8%（1827份）的滑液取自女性，59.2%（2648份）取自男性。晶体识别的频率差异很大：女性中CPPD晶体识别率为13.2%，男性为10.9%；MSUM在1.5%的女性中被识别出，在10.9%的男性中被识别出。CPPD和MSUM阳性滑液的关节受累谱几乎相同。例外情况是，肩关节中CPPD的识别频率更高（CPPD:MSUM = 15.6:1），踝关节（MSUM:CPPD = 15.6:1）和第一跖趾关节（MSUM:CPPD = 8:1）中MSUM的识别频率更高。在MSUM阳性样本中，临床怀疑与晶体识别相关性良好（60%），但在CPPD阳性样本中相关性较差（36%）。与典型痛风相比，焦磷酸关节病的临床表现缺乏特征性，这可以解释CPPD阳性滑液中临床怀疑与晶体识别之间的相关性较差。在穿刺困难因而很少进行穿刺的关节或关节周围肿胀处（如腱鞘、第一跖趾关节和第一掌指关节），发现了很高比例的晶体识别，这突出了尽管关节穿刺困难，但滑液抽吸的重要性。
