2- Crystal-Induced Synovitis (Gout & Psuedogout)

Question 1

Gout vs Psuedogout 🔑🔑 MOCK

Answer 1

Question 2

List 5 Sequelaes of Gout 🔑

Answer 2

1. Gouty arthritis
2. Acute recurrent attacks
3. Chronic tophaceous arthritis
4. Uric acid calculi “uric acid stone”
5. Urate nephropathy “uric acid nephropathy”

Cuccurollo 4th Edition Chapter 3 Rheumatology pg120

Question 3

List 5 triggers of Gout 🔑🔑 MOCK

Answer 3

DIETERY

1. Alcohol ingestion
2. Dietary excess of purines (red meat and seafood)
3. Fructose drink ingestion

DEHYDRATION

1. Rhabdomyolysis/Exercise
2. Drugs—thiazides, loop diuretics
3. Hemorrhage or Hemolytic processes

STRESS

1. Trauma
2. Surgery (postoperative days 3 to 5)
3. Acute medical illness including infections
4. Radiation therapy

Cuccurollo 4th Edition Chapter 3 Rheumatology pg120

Question 4

How is a diagnosis of gout established? 🔑🔑

Answer 4

💡 CBC - Special - Something to see/look

1. CBC & Inflammatory markers
   
   1. High ESR
2. High serum uric acid
3. Synovial fluid
   
   1. Elevated WBC >20,000
   2. MSU crystals
   3. Negative birefringent test

Question 5

List 4 findings in this xray for patient with gout. (2 Marks)🔑

Answer 5

1. Tophi appear as nodules
2. Soft-tissue swelling
3. Bone erosions (periarticular)
4. Joint space is preserved
5. No osteopenia

Cuccurullo 4th Edition Chapter 3 Rheumatology pg20

Question 6

List treatment options for gout 🔑🔑

Answer 6

ACUTE

1. Colchicine 1.2 mg followed by 0.6 mg 1 hour later
2. Naproxen sodium (Anaprox) 750 mg mg once, then 250 mg every 8 hours for 7 days
3. Intra-articular steroid injection
   
   • Large monoarticular flare
4. Allupurinol
   
   • Starting may intensify and prolong the attack.
   • If the patient has been on a consistent dosage of allopurinol at the time of the acute attack, the drug should be continued at that dosage during the attack.
   • If attacks are recurrent or evidence of tophaceous or renal disease is present, therapy for control of hyperuricemia is indicated.
5. Do not use aspirin, because it can alter uric acid levels and potentially prolong and intensify an acute attack.
6. Prednisone 40 mg for 1-3 days tapered over approximately 2 weeks
   
   • Patients with gout who cannot use NSAIDs or colchicine.

CHRONIC

• Allopurinol (Zyloric)
  
  • Two weeks after attack
  • Start 100mg & add 50mg q3-4 days to reach 300mg once daily
  • Uric acid level <400 µmol/L or <7 mg/dL

https://emedicine.medscape.com/article/329958-treatment#d8

Question 7

List 3 reasons for allopurinol use. 🔑🔑

Answer 7

MOA

• Blocks production of uric acid.

NOTE

• Not indicated for asymptomatic hyperuricemia.

INDICATIONS → Sequelaes

1. Tophi
2. Renal uric acid stones.
3. Prevent recurrent attacks of gout (lowers uric acid level).

Ref: current dx and tx rheumatology pg 954.

Review Course notes: urate overproduction, tophi, nephrolithiasis, renal insufficiency

Question 8

What are the most likely diagnoses in hospitalized patients who develop acute monoarticular arthritis following admission for another medical or surgical disease?

Answer 8

1. Acute gout
2. Pseudogout
3. Infection
4. Septic arthritis → Gram stain and culture

Question 9

List 6 specific conditions associated with pseudogout (CPPD). 🔑🔑

Answer 9

HIGH

1. Hyperparathyroidism
2. Amyloidosis
3. Hemochromatosis

LOW

1. Hypothyroidism
2. Hypophosphatemia
3. Hypomagnesemia

Cuccurollo 4th Edition Chapter 3 Rheumatology pg120

Question 10

Treatment options for Psuedogout

Answer 10

Just like OA flare up

• Ice packs, temporary rest
• Aspiration of the affected joint with removal of the offending CPP crystals
• 40 mg of oral prednisone daily, which is tapered to zero in 10 to 14 days
• Triamcinolone joint injection 10-20mg small joint and 40mg large joint
• Hydroxychloroquine and methotrexate

Question 11

Treatment options for Psuedogout

Answer 11

1. Illness (MI, CVA)
2. Trauma
3. Surgery
4. Idiopathic
5. Metabolic disease
6. Hereditary—articular chondrocalcinosis

Cuccurollo 4th Edition Chapter 3 Rheumatology pg120

Question 12

Figure

Answer 12

(A) Acute gouty arthritis, marked by an abrupt onset of pain, erythema, swelling, and warmth in the right first metatarsophalangeal joint.

(B) Chronic tophaceous gout of hands with resultant deformity.

Question 13

How go distinguish between RA & CPPD?
Another wording: 5% have same Hx & PEx. Investigations must be different.

Answer 13

Key Differences in RA

1. More widespread synovitis, involvement of the hands and feet
2. Higher RF titers
3. Antibodies against cyclic citrullinated peptide
4. Characteristic erosions

Question 14

What are the acquired causes of hyperuricemia?

Answer 14

Urate overproduction: excess dietary purine consumption, fructose, alcohol

Urate underexcretion: renal disease, hypothyroid, lasix, thiazides

Rheumatology Secrets 4th Edition Chapter 45 Gout pg365