17- Gout

Question 1

=Give some general info on Gout

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Answer 1

Disorder of purine metabolism in which hyperuricemia leads to deposition of sodium monourate crystals into cartilage, synovium, periarticular and subcutaneous tissue
-crystals evoke a strong inflammatory arthritis usually in lower extremity
− The feet are most commonly involved
− Primarily a periarticular process
− Due to purine metabolism disorder, a primary enzyme defect, in which too much is
made, not enough excreted
− Tophus- chalky white deposits of uric acid
-the arthritis is induced by intra-articular deposits of sodium monourate. Some patients develop aggregations of these crystals which lead to destructive and deforming arthropathy (disease of a joint)
-the most common manifestations are musckuloskeletal in nature, especially effecting the feet.
-the spins shows radiographic changes only in advanced stages.

Question 2

What is some clinical information on gout?

Answer 2

− M>F 20:1, usually over 40 years old at time of onset. Also, post-menopausal patients
on diuretics
− Family history common
− Associated with consumption of organ meats, shellfish, rich foods
− Secondary-drug interaction
− Initial onset usually very acute and painful
− May become polyarticular if chronic

Question 3

What is the acute phase of gout?
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Answer 3

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− Attack usually early morning
− 60% at 1st MTP joint (lower extremities)
− affected joint is swollen, hot but dry (in contrast to other arthritides),
rapid recovery in days of attack − Many patients are asymptomatic for years

Question 4

What is the polyarticular phase of gout?

Answer 4

− Multiple attacks of acute phase predispose patient to more than one joint at a time being involved
− This stage is where radiographic changes are first seen
-in addition the small joints of the hand, wrist, and elbow may be affected

Question 5

What is the chronic Tophaceous Phase?

Answer 5

-in long standing gout the localised accumulations of sodium monourate (tophi)
-the onset of tophi deposits follows numerous attacks over the years.
-Tophi now unusual due to drugs
− Tophi seen after several attacks over many years (10-12 yrs)
− Tophi seen in synovium, cartilage, ligaments, subchondral bone

Question 6

What are the radiographic feature of Gout?

Answer 6

• dense soft tissue tophi (a calcareous concretion formed in the soft tissue about a join)
• preservation of joint space, bone erosions, normal bone density
• secondary degenerative joint changes
• chondrocalcinosus and avascular necrosis
• Most targeted spot is 1st MTP joint, other MTP joints , hand and wrist

− Radiographic signs lag behind clinical features by 5-10yrs
− Joint space preserved until late
− Soft tissue swelling, bursal enlargement
− Tophi eccentric, periarticular
− Bone erosion, “overhanging margin”
− Bone density remains normal
− DDX: inflammatory arthritities, hallux rigidus

Question 7

Targeted sites of involvement
Foot
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Answer 7

− Most distinctive location: 1st MTP
− Swelling, tophi deposits in soft tissue
− “Overhanging margins”, periarticular erosions
− Normal bone density
− Late stage, narrowing of joint

Question 8

Targeted sites of involvement

Hand/wrist

Answer 8

− Asymmetric joint involvement
− Erosions, soft tissue swelling, misalignments
− “Spotty carpals”, carpal/metacarpal joints involved − Bone density is normal