Recurrent Monoarthritis in a 40-Year-Old Woman
Bibliographic record
Abstract
Background Calcium pyrophosphate deposition (CPPD) disease is typically a disease of older age and is male-predominant.[1] It can present as various phenotypes, including acute monoarthritis, polyarthritis resembling osteoarthritis with intermittent flares, and polyarticular disease resembling rheumatoid arthritis.[2] In younger patients affected by CPPD, a metabolic workup is warranted to assess for secondary causes. Case A 40-year-old woman with a past history of Grave’s disease presents to the emergency room with left wrist pain and swelling, alongside a five-year history of intermittent monoarthritis affecting various joints, including ankles, wrists, knees and shoulders. Each episode resolved spontaneously within 5 days, raising a suspicion of crystal-induced arthritis. Initial treatments with NSAIDs, followed by a combination of colchicine, hydroxychloroquine, and methotrexate provided minimal relief, and flare-ups were occurring twice monthly. Steroids were effective but caused significant side effects even with short-term use. Physical examination revealed a left wrist effusion and tenderness over the right sternoclavicular joint. Imaging of the left wrist demonstrated significant chondrocalcinosis with dense mineralization of the ulnocarpal space and intercarpal hyaline cartilage. Ultrasound identified a small radiocarpal joint effusion with synovial thickening, nodularity, and hyperemia that were compatible with synovitis. The imaging findings were compatible with CPPD arthropathy with active inflammation at the wrist. Initial synovial fluid analysis was negative (left wrist) but subsequently positive in the knee, confirming CPPD crystals. Laboratory evaluation revealed significant hypomagnesemia of 0.45 mmol/L (normal range 0.66-1.07 mmol/L). Despite ongoing oral magnesium supplementation, her hypomagnesemia persisted, and renal wasting was confirmed by the fractional extraction of magnesium (FeMg) in a 24-hour urine collection. Genetic testing revealed a heterozygous pathogenic variant in HNF1B, which is associated with renal magnesium wasting and polycystic kidney disease. Due to the inadequate response to the conventional disease-modifying agents and persistent recurrent monoarthritis, the patient was given on-demand anakinra, which shortened the duration of her flare-ups and reduced her need for corticosteroids. Since recurrent episodes continued, anakinra was changed to daily dosing, which essentially abolished the episodes, contributing to an improved quality of life. Conclusion This case highlights the importance of assessing for secondary causes of CPP disease, particularly in younger individuals. Hypomagnesemia is a crucial risk factor as it plays a key role in regulating pyrophosphate crystal formation. This case illustrates how ongoing hypomagnesemia can lead to resistant CPP disease that responds poorly to traditional agents and the benefits of an IL-1 inhibitor in disease management. [1.] Pascart T. Lancet Rheumatol 2024;6(11):e791-804. [2.] Abhishek A. Curr Opin Rheumatol 2016;28(2):133-9.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.002 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.002 | 0.001 |
| Science and technology studies | 0.002 | 0.001 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.003 | 0.002 |
| Insufficient payload (model declined to judge) | 0.003 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".