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Synovial fluid from OA joints is usually non inflammatory or mildly inflammatory with less than 2000 white blood cells/mm3, predominantly mononuclear cells. Inflammatory effusion in OA may occur in the presence of calcium pyrophosphate crystals. calcium pyrophosphate deposition may be present in as many as 30 to 60 percent of unselected OA patients . Most patients with OA and CPP deposition are older than 60 years, and common target sites are the knees, radiocarpal joints, second and third MCP joints, shoulder, and elbow joints . The presence of calcium pyrophosphate deposition may modify OA symptoms at that site, especially with longer early morning stiffness and more signs of synovitis. The symptoms may be acute with marked pain, swelling, and tenderness, at its worst within 6 to 24 hours, typically lasting from a few days to one to two weeks; intermittent; or low-grade and persistent. Joint swelling, warmth, and tenderness may be more common and more pronounced than in OA without calcium pyrophosphate deposition. Joint effusions are common and may be hemorrhagic or turbid on aspiration. Large joint effusions may leak into the surrounding soft tissues and lead to localized pain, swelling, and extensive bruising, especially at the shoulder and knee. Symptoms are mostly restricted to one or a few joints at a time, but polyarticular involvement can occur, especially involving knees, wrists, and MCP joints, that superficially may mimic rheumatoid arthritis. Although studies give conflicting results, it is likely that OA with calcium pyrophosphate deposition is not any more rapidly progressive than OA alone, and patients with end-stage knee OA with calcium pyrophosphate deposition do not have any more difficulty with activities than those with end-stage knee OA alone. However, a few patients with calcium pyrophosphate deposition do appear to develop rapidly progressive destructive arthropathy at the knees, shoulders, or hips.