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Year 2 Loco > 19. Crystal arthropathies (Robson) > Flashcards

19. Crystal arthropathies (Robson) Flashcards

1
Q

What is gout?

A

Where defective metabolism - poor renal excretion - of uric acid results in arthritis

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2
Q

What is the prevalence of gout?

A

1% of the population

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3
Q

What are the different facto categories that result in the onset of gout?

A

Environmental
Dietary
Genetic

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4
Q

Is gout more common in men or women?

A

Men

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5
Q

Why is gout more common in men?

A

Because men have higher levels of uric acid then females

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6
Q

When does the level of uric acid rise in men?

A

In boys - around the age of puberty

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7
Q

When does gout present in men?

A

Around the age of thirty

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8
Q

How long does it take for the onset of gout to occur?

A

About 20 years after the uric acid levels rise

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9
Q

How does gout occur?

A

Uric acid flares and crystalises to form monosodium urate crystals - these crystals can then be attacked by the immune system and arthritis in the form of gout forms

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10
Q

What are the crystals that are formed in gout?

A

Monosodium urate crystals

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11
Q

Where are the crystals deposited in gout?

A

Deposited in the soft tissues - joints, articular capsule, tendons, ligaments, cartilage

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12
Q

When does the level of uric acid increased in women?

A

Around the age of the menopause

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13
Q

What is the most common site of gout in an individual and why?

A

The big toe - the first metataral joint

Because it is slightly colder than the rest of the body and has a slightly lower pH due to reduced perfusion - the favourable conditions for the development of gout

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14
Q

When can gout result in joint destruction?

A

If it is untreated and there are repeated attacks of gout at the same joint

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15
Q

What is the main organ concerned with the formation of gout and why?

A

Kidney

Sufficient renal excretion of uric acid is not occurring

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16
Q

How is uric acid produced?

A

By the breakdown of purines - metabolism of purines results in the production of uric acid

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17
Q

When is uric acid present in an individual?

A

Uric acid is present in everyone at all ages in the form of the monosodium urate crystals - but does not cause a problem because it is inert

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18
Q

Why do monosodium urate crstals not normally result in gout?

A

Uric acid is normally inert

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19
Q

How are monosodium urate crystals made inert?

A

The crystals are coated by proteins - these are apolipoproteins that are highly negative and this hides the crystals from the immune system

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20
Q

If the monosodium urate crystals are inert, why does gout occur?

A

If there is an increased level of crystals that are forming - large change in concentration then there can be too great a level for the serum protein to coat them all

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21
Q

What is the saturated level of the crystals to be coated by the proteins?

A

68mg/dl

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22
Q

What are the conditions required for the precipitation of the crystals from uric acid?

A

Low temperature - a drop of two degrees compared to normal

Reduced pH

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23
Q

What is the main white blood cell involved in gout?

A

Neutrophils

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24
Q

Which receptor on neutrophils is activated by the non-coated crystals?

A

IL1

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25
Q

What is the mode of action of the neutrophils to the gout crystals and what does this result in?

A

Neutrophils are phagocytic and they ingest the crystals - the crystal then pops/bursts the neutrophil from within and all the contents is exposed into the environment

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26
Q

What is the effect of the bursting of neutrophils on the surrounding environment and why?

A

Lowers the pH - release of very acidic lysosomes

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27
Q

What is the effect of the bursting neutrophils on crystal formation?

A

The bursting of neutrophils lowers the pH - this is favourable for the precipitation of crystals - more crystals from - recruits more neutrophils - cycle continues

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28
Q

What is ‘podagra’?

A

Inflammation of the first MTP joint in gout - the most common joint that is affected - 50% of cases

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29
Q

Is gout mono or poly articular?

A

Monoarticular - 90% of cases

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30
Q

What is the first symptomatic period of gout?

A

Begins suddenly and there is a maximum intensity of pain within the first 8-12 hours

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31
Q

How intense is the maximum intensity of pain in patients with gout?

A

So intense that these patients cannot even take the weight of a sheet over the affected foot

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32
Q

How long does the first flare of gout normally last for?

A

Normally resolves within about 2-3 weeks - provide painkillers and inflammation goes and everything calms down - no other treatment required for the first attack

33
Q

What are the types of joints commonly affected by gout?

A

Tends to stay out in the periphery and in the smaller joints

34
Q

Other than joints, what else can be affected by gout?

A

Organs e.g. kidney

Bursa

35
Q

How does the affected joint present in a patient with gout?

A

Red
Hot
Exquisitely tender
Pain starts acutely and usually at night

36
Q

Why does the pain from gout usually start at night ?

A

Usually starts around 2am because of circadian rhythm - this is when you are the coldest

37
Q

How will gout present throughout someones life after the first attack?

A

Very variable - some people will have just one attack - some people will have a progressive form which gets worse each time and becomes polyarticular

38
Q

How does untreated gout progress?

A

Attacks can become polyarticular
More proximal and upper extremity joints involved
Attacks become more frequent and last for longer
Polyarticular and will become almost symmetrical

39
Q

What are ‘tophi’?

A

This is the deposition of the crystals in and about the synovial joint - so in the soft tissue and the synovial fluid etc.

40
Q

How can gout be recognised on an x-ray?

A

Tophi

Joint erosions - ‘rat bites’

41
Q

Where do joint erosions occur in gout?

A

Do not occur right at the joint - are at the insertion of the articular capsule - called ‘rat bites’ and have overhanging edges

42
Q

Are tophi only visible on n x-ray?

A

No - occur in the soft tissues so will be able to see them under the skin

43
Q

In what percentage of people with gout do tophi occur?

A

In 50% of these people

44
Q

When do tophi occur?

A

Occur after 10 years of gout

45
Q

What will be visible on a biopsy of gout?

A

Tophi will be visible as a nodule - histocytes surround the crystals and then lymphocytes surround this -forms a nodule

46
Q

What are histocytes?

A

These are macropahges that are not located in the bloodstream

47
Q

Why will the crystals not be physically present on a biopsy?

A

Crystals are present in the nodules but they are soluble - will be washed out during the procedures of the biopsy

48
Q

How do humans normally remove uric acid from the system?

A

70% in urine

30% in faecal matter

49
Q

Where is uric acid obtained from?

A

Small amount is obtained fro the diet

Majority is produced by metabolism of purines

50
Q

Which foods result in a high uric acid consumption?

A

Meat - beef, pork, lamb
Alcohol (yeast) - bear, red wine
Seafood - tuna

51
Q

Other that food, what are other risk factors for the development of gout?

A 
Thiazide diuretics !!
Dehydration
Renal insufficiency 
Male gender
Increasing age 
Increased fructose intake eg. in drugs
52
Q

What are the different causes of hyperuricemia that can lead to gout?

A 
Joint inflammation 
Kidney or bladder stones
Nephropathy
CV disease
Metabolic syndrome
53
Q

What is hyperuricemia?

A

High levels of uric acid

54
Q

What is the appearance of the synovial fluid in someone that has gout?

A

Will be packed full of neutrophils - white and creamy

Will also look slightly shiny - glisten when held up to the light -presence of crystals

55
Q

What is the appearance of the crystals in gout?

A

These are sharp, needle like and very shiny

56
Q

Is hperuricemia diagnostic for gout and why?

A

No - 5-8% of the population have naturally elavated serum uric acid levels anyhow (and still do not have gout)

Not just requirement of hyperuricemia - also need cold temperature and low pH

57
Q

How will gout show on a doppler ultrasound?

A

There will be an increased blood flow

58
Q

Why and how does joint damage occur in gout?

A

RANKL is stimulated

RANKL stimulates the production and proliferation of osteoclasts and osteoclast precursors - erosion of bone

59
Q

Which inflammatory cytokines are involved in gout?

A

IL1
TNF-alpha
IL6
(RANKL)

60
Q

Give four drug groups that can be used in the treatment of acute gout

A

NSAIDs
Colchicine
Corticosteroids
IL1 biologicals

Also change in diet

61
Q

What is colchicine?

A

Antimitotic - this stops cell division and stops the proliferation of the neutrophils

62
Q

Why is colchicine not so commonly used anymore?

A

Has a narrow therapeutic window and also has a risk of toxicity

63
Q

Four treatments of chronic gout are?

A

Allopurinol
Probenecid
Rasburicase
Altered diet

64
Q

What is pseudogout?

A

Deposition of calcium salts in soft tissues - if these come into contact with exposed bone then they can precipitate

65
Q

What are the calcium salts involved in psuedogout?

A

Calcium pyrophosphate dihydrate crystals

66
Q

What is the most commonly affected joint in peudogout?

A

The knee

67
Q

NEED TO COMPLETE FROM SLIDE 23 ONWARDS

A

NEED TO COMPLETE FROM SLIDE 23 ONWARDS

68
Q

What is the appearance of the crystals in pseudogout?

A

Short and stubby - not as shiny

69
Q

What is chondrocalcinosis?

A

Calcification within the soft tissue

70
Q

How does chondrocalcinosis appear on an ultrasound?

A

Appears as an extra line below the normal surface

71
Q

What is the age group that is affected by pseudogout?

A

The elderly

72
Q

Two immune cells that are present around gout nodule/tophi are?

A

Histocytes

Lymphocytes (surround histocytes)

73
Q

Mechanism of action of colchicine is?

A

Anti-mitotic - inhibition of the proliferation of neutrophils

74
Q

Mechanism of action of allopurinol?

A

Blocks xanthine oxidase (reduced production of uric acid)

75
Q

Mechanism of action of probenecid?

A

Increases excretion of uric acid

76
Q

Mechanism of action of rasburicase?

A

Catalyses converstion of uric acid to allantoin

77
Q

What is the shape of the crystals in pseudogout?

A

Rhomboid shaped crystals

78
Q

What do the crystals in pseudogout look like?

A

Short and stubby and not as shiny

79
Q

Treatment for pseudogout is?

A

NSAIDs

Year 2 Loco (31 decks)

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