There has been recent interest in the syndrome known as " pseudogout," in which typical acute and even chronic gout has been associated with calcification of certain articular structures and with calcium-containing micro-crystals in the synovial fluid (Kohn et al., 1962 ; Bywaters et al., 1963; McCarty, 1963 ; Brit. med. Y., 1964; McCarty and Gatter, 1964; Scott et al., 1964; Vix, 1964). McCarty and Gatter (1964) showed that these crystals were composed of calcium pyrophosphate. Although the

more »

... tially reported cases had normal serum calcium levels, a similar condition occasionally occurs in hyperparathyroidism, and some of the affected patients have had high levels of both serum uric acid and calcium. Bywaters et al. (1963) commented upon five such patients, considering them to have had true uric acid gout. However, as the British Medical 7ournal (1964) remarked, " the question will remain open until the synovial fluids of such cases are examined for crystals." We have recently examined synovial fluid from such an individual, but the question still remains open, because both urate and calcium phosphate crystals were found. CASE REPORT An overweight white man aged 49 gave a 14-year history of renal colic and renal stone formation. Both nephrostomy and partial left-sided nephrectomy had been performed. He took little alcohol and gave no family history of gout or renal stones. He had suffered from gouty arthritis for five years, with attacks of red, swollen, tender joints lasting several days, affecting mainly the knees, ankles, and right hip, and responding to colchicine with reasonable celerity. We observed one typical and severe attack in the big toe, which abated over several days on full doses of colchicine. The level of his serum calcium was raised, 12-14 mg./100 ml. (several readings) ; serum phosphorus 1.5-2.5 mg./100 ml. ; 24-hour urine calcium 300-400 mg. ; serum uric acid 7-11 mg./100 ml.; and blood urea between 40 and 50 mg./100 ml. Renal function was shown later to be virtually normal. Physical examination revealed nothing beyond small white tophi in both ears. Radiographs of the bones were normal, but there was calcification in the medial meniscus of the right knee and in the patellar ligament. There was also calcification of the soft tissue beneath the right heel. While in hospital he suffered an attack of acute pancreatitis, with severe pain and shock. He later became jaundiced (serum bilirubin 4.2 mg./,100 ml.) and developed an epigastric mass which slowly subsided. He gradually recovered under gastric aspiration and intravenous fluid therapy, and the gall-bladder was later shown' to function normally.