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Block 6 > 7.1 Crystal Arthropathy > Flashcards

7.1 Crystal Arthropathy Flashcards

1
Q

What is the most common cause of inflammatory arthritis in older people?

A

Gout

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2
Q

Why is there an increased prevalence of gout?

A

Longevity of life
Increased vascular diseases and use of diuretics
Renal diseases
Immunosuppressive therapy
Obesity and associated metabolic syndrome
Dietary trends
Limitations of existing therapies

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3
Q

What is the most common site of crystal arthropathy and why?

A

The big toe because it is colder and that is what causes uric acid to crystalise

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4
Q

what is the level of uric acd supersaturation and what happens?

A

0.40 mol/L this causes it to precipitate into tissues

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5
Q

When does a gouty attack occur?

A

When monosodium urate crystals are released or form de novo in the joint space

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6
Q

What can cause a gouty attack?

A

Trauma, surgery, infections and initiations of medications such as allopurinol and diuretics

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7
Q

What is the pathophysiology of a gouty attack?

A

Monosodium urate crystals are phagocytosed by leukocytes

Crystals trigger inflammation by proteins called inflammasome

The inflammasome potentiates IL-1 converting enzyme forming active interleukin 1B which acts on target tissues

This leads to the release of other inflammatory mediators such as cytokines, prostaglandins and vasoactive peptides

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8
Q

what is inflammasome production mediated by?

A

NOD like receptors protein that carries an N-terminal pyrin domain (NLRPs) or a capase-recruitment domain (CARD)

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9
Q

What can cause auto-inflammatory diseases?

A

Mutations in the genes encoding for components of the inflammasome that leads to processing and secretion of proinflammatory cytokines suck as IL-1b

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10
Q

What are the common sites of gout flares?

A 
1st MTP 
midfoot 
Subtalar 
Ankle 
Knee 
Olecranon bursae 
Elbow 
Wrist 
Fingers
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11
Q

What are the initial investigations for asymptomatic hyperuricaemia?

A

Fasting lipid profile and BSL, 24h urine excretion of uric acid

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12
Q

What are the initial investigations for monoarticular and polyarticular gout?

A

FBC, CRP and blood cultures
Serum uric acid, EUC, LFTs, fasting lipid profile, BSL
Synovial fluid for gram stains, culture and crystals

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13
Q

What is the old standard for a diagnosis of gout?

A

MSU crystals

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14
Q

What is the appearance of Calcium Pyrophosphate Deposition Disease crystals?

A

Rhomboidal or rectangular shape

No as positively birefringenet as MSU - Will appear blue if they are

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15
Q

What is the appearance of MSU crystals?

A

Brightly birefringent and needle shaped

Appear yellow

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16
Q

What is the treatment for asymptomatic hyperuricaemia?

A

Assess the chance of developing gouty arthritis

  • Urolithiasis, renal impairment or acute uric acid nephropathy
  • Underlying overproduction
  • Therapeutic interventions
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17
Q

What is the aim of gout treatment?

A

Reduce SUA levels to below 0.36 mmol/L

Prevent gouty attacks

18
Q

What are the indications for urate lowering therapy?

A

Recurrent attacks, chronic tophaceous gout, radiographic changes, gout with coexisting nephrolithiasis or renal insufficiency, metabolic syndrome, diuretic therapy

19
Q

What are the urate lowering drugs available?

A

Xanthine oxidase inhibitors: allopurinol
Uricase enzyme analogue: rasburicase
Increase excretion: losartan
Action on proteins preventing phagocytosis: colchcine
Glucocorticoids
NSAIDs

20
Q

What are the joints involved in pseudogout?

A

knees, wrists, shoulders, hips and ankles

21
Q

What is pseudogout?

A

Pseudogout results from the abnormal formation of calcium pyrophosphate (CPP) crystals in the cartilage (cushioning material between the bones), which is later followed by the release of crystals into the joint fluid.

22
Q

What are the DD for pseudogout?

A

gout and septic arthritis

23
Q

What is the diagnosis of pseudogout?

A

calcium pyrophosphate crystals in synovial fluid

Chondrocalcinosis on imaging

24
Q

What is the treatment for pseudogout?

A

NSAIDs, glucocorticoids and cochicine
Joint asporation
Treat any underlying metabolic condition

25
Q

What needs to be assessed with synovial fluid?

A

Volume, clarity, colour and viscosity

26
Q

What causes opacity of synovial fluid?

A

Abnormally large numbers of nucleated or red blood cells

27
Q

What causes translucent synovial fluid?

A

Acellular material such as lipids, cholesterol crystals, monosodium urate crystals

28
Q

What causes different colours in synovial fluid?

A

Clear is normal

Yellow/yellow green: due to increasing amounts of plasma and nucleated cells (inflammatory or septic)

Red/rusty.chocolate: fresh or old blood

29
Q

What is the normal viscosity of synovial fluid and what causes changes?

A

Normal: As exxpelled from syringe and allowed to drop it will produce a long string like extension

Decrease viscosity is due to release of proteolytic enzymes into inflamed synovial fluid

30
Q

What is important to look at in synovial fluid?

A

WCC for septic arthritis

31
Q

When should you not take fluid?

A

When there is a large amount of swelling as you don’t want to cause systemic infection

32
Q

When should you suspect septic arthritis?

A

Acute monoarthirtis, worsening of chronic joint diseases in a single joint - especially if immunosuppressed

33
Q

What should always be included in synvoial fluid analysis?

A

cell count, gram stain, cultures and crystal analyss

34
Q

What should you do with suspected septic arthritis even with crystals?

A

Start on empiric antibiotics - vancomycin until results suggest methicillin susceptible pathogen

35
Q

What is the most common cause of septic arthritis?

A

Staph aureus

36
Q

In who is gram negative joint infections more common?

A

elderly, immunosuppressed, post-operative patients, indwelling catheters

37
Q

What are the symptoms of disseminated gonococcaemia?

A

tenosynovitis, polyarthralgia, migratory arthritis and cutaneous lesions

38
Q

What are the radiological features of out?

A

Erosions with overhanging margins
Sclerotic margins
Relatively well preserved joint space
Soft tissue trophii

39
Q

What are the DD for gout?

A

SEPTIC ARTHRITIS
Mono: haemarthrosis, pseudogout, seronegative arthropathy

Poly: RA, psoiatic arthritis, primary generalised OA

40
Q

What is the presentation of acute gout?

A

Severe pain, swelling, erythema
Acute onset
80% first attacks are monoarticular (1st MTP)

Block 6 (48 decks)

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