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Rheumatology > 1: Crystal Arthritis > Flashcards

1: Crystal Arthritis Flashcards

1
Q

What is crystal arthritis

A

arthritis caused by accumulation of crystals in one or more joints

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2
Q

what are two types of crystal arthritis

A
  • Gout

- Pseudogout

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3
Q

what crystals are seen in gout

A

Uric acid ( monosodium urate crystals)

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4
Q

what crystals are seen in pseudogout

A

calcium oxalate

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5
Q

define gout

A

Inflammatory arthropathy due to deposition of uric acid crystals

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6
Q

which gender does gout affect more

A

males (3:1)

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7
Q

what age is peak incidence of gout

A

30-60y

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8
Q

what ethnicity is gout most likely to occur in

A

African Americans

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9
Q

what causes gout

A

Deposition of monosodium urate crystals in a joint

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10
Q

what condition predisposes to gout

A

Hyperuricaemia

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11
Q

where is uric acid produced

A

by metabolism of purines

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12
Q

how is uric acid excreted

A

renal

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13
Q

how may hyperuricaemia occur

A

due to increased production, metabolism or decreased excretion of uric acid

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14
Q

How can the aetiology of hyperuricaemia be divided

A
  • Increased production

- Decreased excretion

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15
Q

what are the 3 categorical causes of hyperuricaemia

A
  1. High cell turnover
  2. Enzyme defects
  3. Products high in purines
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16
Q

what are 4 causes of high cell turnover leading to hyperuricaemia

A
  1. Tumour lysis syndrome
  2. Myeloproliferative disorders
  3. Chemotherapy/Radiotherapy
  4. Haemolytic anaemia
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17
Q

why does haemolytic anaemia cause hyperuricaemia

A

It is caused by a high-turnover of reticulocytes (which have nucleus, hence DNA and purines) and NOT RBC - as they have no nucleus.

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18
Q

what enzyme defect can lead to hyperuricaemia

A

Lesh-Nyhan Syndrome

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19
Q

what is lesh-nyhan syndrome

A
  • Occurs solely in males

- Individuals present with behavioural and neurological abnormalities due to increased production of uric acid

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20
Q

what are 4 products high in purines

A

Shellfish
Anchioves
Organ meat
Red meat

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21
Q

what are 4 causes of decreased uric acid excretion

A
  1. Dehydration
  2. Chronic renal insufficiency
  3. Medications
  4. Acidosis
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22
Q

what may lead to dehydration

A
  • Decreased water intake

- Excess alcohol intake

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23
Q

what are 3 medications that may cause hyperuricaemia

A

Thiazides
NSAIDs
Loop diuretics

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24
Q

what may result in acidosis

A

DKA

Lactic acidosis

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25
Q

what are two risk factors for hyperuricaemia

A

Diabetes

Obesity

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26
Q

How does hyperuricaemia present clinically

A

asymptomatic (can be asymptomatic for up to 20y)

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27
Q

How does gout present

A
  • sudden-onset monoarticular joint pain reaches maximal intensity at 12h
  • erythema, swelling and warmth of the joint
  • decreased range of movement
  • more likely at night
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28
Q

When is gout pain more common

A

nocturnal

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29
Q

what joint do 70% of gouty attacks affect

A

the first metatarsophalangeal joint

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30
Q

what is it called when gout affects the first meta-tarso phalangeal joint

A

Podgra

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31
Q

what is podgra

A

Gout of the first MTP joint

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32
Q

what is gonagra

A

Gout of the knee

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33
Q

what is chiragra

A

Gout of the first MCP joint of the thumb

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34
Q

what is chronic gouty arthritis

A

When recurrent acute attacks of gout lead to progressive degenerative arthritis

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35
Q

what may be seen in chronic gouty arthritis

A

Gouty tophi

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36
Q

what are gouty tophi

A

Painless hard nodules

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37
Q

when may bony tophi be seen

A

Deposition of monosodium urate within bone

38
Q

when may soft tissue tophi be seen

A

Deposition of monosodium urate within soft tissues. Common site includes the ear

39
Q

what are two renal manifestations of gout

A

Nephrolithiasis

Uric acid nephrpathy

40
Q

Explain pathophysiology of gout

A

Gout is due to hyperuricaemia, which results in sharp needle-like crystals. This accumulate in joints and renal tubules, reducing blood flow and hence causing damage

41
Q

What are purines a component occurs

A

RNA + DNA

42
Q

What happens when physiological cell destruction occurs

A

Purines are released and converse to uric acid

43
Q

How is uric acid removed

A

in urine

44
Q

When does hyperuricaemia occur

A

when production of uric acid exceeds its solubility in body fluids

45
Q

how are monosodium urate crystals formed

A

in acidic conditions, uric acid looses a proton to become an ion which can then bind to sodium

46
Q

What are 6 investigations ordered in gout

A
  1. Arthrocentesis
  2. FBC, CRP
  3. US
  4. MRI
  5. Serum uric acid
  6. X-ray
47
Q

when is arthrocentesis indicated in gout

A

For all cases of acute gout

48
Q

what is joint fluid sent for

A

Polarised light microscopy

49
Q

what will be seen on polarised light microscopy in gout

A

Negatively birefringent monosodium urate crystals

(Remember as:
UR Negative)

50
Q

what else will be seen in synovial fluid

A

WBC >2000

Neutrophils >50%

51
Q

how will serum uric acid present in gout

A

Raised

52
Q

how will FBC, CRP be changed in gout

A

Raised

53
Q

what may be seen on US in gout

A

Double contour sign

54
Q

why may MRI be performed in gout

A

Identify tophi

55
Q

when is an x-ray indicated for gout

A

Chronic gout. Not acute gout where there are recurrent attacks

56
Q

what is a finding of chronic gout arthritis on x-ray

A

‘punched-out’ lesions

57
Q

how can gout be differentiates from OA and RA on x-ray

A 
OA = loss of joint space 
RA = junta-articular osteopenia
  • neither findings present in gout
58
Q

How are acute attacks of gout managed

A
  1. Advice + Self-Management
  2. Colchicine or NSAIDs
  3. Intra-articular corticosteroid injections or short-course oral corticosteroids
59
Q

What advice should be offered in acute gout

A
  • use ice packs (cold temp)
  • Lifestyle changes
  • Rest and elevate the limb
60
Q

what medication is first line for gout

A

NSAIDs or Colchicine

61
Q

what dose of NSAIDs should be given in gout and for how long

A

Start at a high dose for 1-2d. Prescribe with PPI

62
Q

If individuals have co-morbidities and are unable to tolerate colchicine or NSAIDs, what should be offered

A

Short course oral corticosteroids or intra-articular corticosteroid injections

63
Q

What should be offered to all individuals with a diagnosis of gout

A

Urate lowering therapies - to prevent attacks of gout

64
Q

What are 7 indications in particular for urate lowering therapy

A
  • More than 2 attacks in 12m
  • Tophi
  • Evidence arthritis
  • Renal impairment
  • Hx urate stones
  • Diuretic use
  • Young age first-onset
65
Q

what is first-line urate lowing therapy

A

Allopurinol

66
Q

explain dosing of allopurinol

A

Start at lowest dose an titrate up every 4W until serum uric acid is <300

67
Q

what is second-line urate lowering therapy

A

Febuxostat

68
Q

when is febuxostat indicated

A

If individual has CI or is not tolerating allopurinol

69
Q

what should be checked prior to starting febuxostat

A

LFTs

70
Q

what should be given when first staring all urate lowering therapies and why

A

Colchicine - as both urate lowering therapies increase risk of acute gout attacks once first started

71
Q

how long is colchicine as prevention continued for

A

6 months

72
Q

what are 3 complications of gout

A
  • Gout arthritis
  • Nephrolithiasis
  • Tuberointerstitial nephropathy
73
Q

what is pseudogout

A

arthritis caused by deposition of calcium pyrophosphate dihydrate (CPPD) crystals in joints

74
Q

how is pseudogout characterised

A

recurrent attacks of mono arthritis

75
Q

in which group if individuals does pseudogout occur more

A

Elderly

76
Q

what causes pseudogout

A
  1. Idiopathic

2. Secondary (see risk factors)

77
Q

what are 6 risk factors for pseudogout

A
  1. Haemochromatosis
  2. Hyperparathyroidism
  3. Low magnesium
  4. Low phosphate
  5. Wilson’s disease
  6. Acromegaly
78
Q

how does pseudogout present clinically

A

Often asymptomatic and may be found incidentally on imaging

79
Q

how will a pseudogout attack present

A

Sudden-Onset pain in monarticular large proximal joints

80
Q

which type of joints does gout affect

A

first metatarsal-phalangeal (MTP) joint = podgra

81
Q

which type of joints does pseudogout affect

A

large proximal joints

82
Q

how does chronic pseudogout present

A

Osteoarthritis - with presence of calcium pyrophosphate dehydrate crystals

83
Q

what are 3 differentiating features of psuedogout from gout

A
  1. Positively befringent crystals
  2. Affects large proximal joints
  3. Older patients
84
Q

what investigations may be performed in psuedogout

A
  1. Joint aspiration
  2. X-ray
  3. Bone profile
  4. Serum urate
85
Q

what is performed on joint aspirate

A

Polarised light microscopy

86
Q

what will polarised light microscopy show

A

Positively befringent rhomboid shaped crystals

87
Q

what else will be present in synovial fluid

A

High WBC count

88
Q

what will an x-ray show in pseudogout

A

Chrondrocalcinosis (calcification of the joint)

89
Q

why may a bone profile be ordered in pseudogout

A

To check for calcium - if hyperparathyroidism

90
Q

how are accessible joints affected by pseudogout treated

A

Intra-articular corticosteroids

91
Q

how are inaccessible joints affected by pseudogout treated

A

Oral NSAIDs with PPI

Or, oral colchicine and paracetamol

Rheumatology (10 decks)

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