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DOI 10.1002/art.30453
Clinical Image: Crystal arthritis induced by intraarticular corticosteroid
The patient, a 22-year-old man with a history of oligoarticular juvenile idiopathic arthritis (JIA), was seen for repeated aspiration
and injection of a right knee effusion. Three months previously, it had been aspirated and injected with 80 mg triamcinolone
acetonide without complication; the aspirate showed inflammatory fluid with no evidence of infection or crystals prior to injection.
On this occasion, ⬃25 ml of cloudy fluid was removed from the knee and 100 mg triamcinolone hexacetonide mixed with 3 ml 1%
lidocaine was injected. Two hours following the injection, the knee swelled markedly and a warm, tense effusion was evident. The
knee was reaspirated for symptom relief and ⬃60 ml of turbid fluid was removed (white blood cell count 72,000 ⫻ 106/liter, negative
Gram stain, and no growth in cultures). Microscopy of the aspirate showed numerous brightly birefringent crystals. The thick arrow
shows the axis of slow vibration of light by the first-order red plate compensator; the yellow crystals with the long axis (parallel to
that arrow) are negatively birefringent and blue crystals with the long axis (parallel to that arrow) are positively birefringent. In
contrast to calcium pyrophosphate crystals, these crystals are much brighter and some are larger than the leukocytes. Eosinophils
were not visualized in the joint fluid. Consistent with the proposed pathogenic mechanism of steroid crystal–induced arthritis,
phagocytosis is demonstrated (thin arrows). Treatment with triamcinolone hexacetonide was chosen on this occasion as it has a
longer active duration in patients with JIA. Although the typical dose of intraarticular steroid is 1 mg/kg, this patient weighed 92
kg and was treated with a slightly larger dose. The patient had had several previous joint injections with triamcinolone acetonide,
but had not been previously treated with triamcinolone hexacetonide.
Douglas White, FRACP
Sean Munroe, BMLS
Waikato Hospital
Hamilton, New Zealand
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