Crystal Arthritis

Question 1

What can cause hyperuricemia?

Answer 1

Overproduction
Underexcretion (MC) - renal insufficiency, diuretic use, dehydration, cyclosporine, lead poisoning, lactic acidosis, ketoacidosis
Mixed

Question 2

A 50 yo male presents complaining of rapid onset, very painful swelling in his big toe. On exam the 1st MTP joint is red, swollen, and extremely tender to touch. What labs should or order based on your suspected diagnosis?

Answer 2

Gout
Serum uric acid
Synovial fluid WBC
ESR (sed rate)

Question 3

A 50 yo male presents complaining of rapid onset, very painful swelling in his big toe. On exam the 1st MTP joint is red, swollen, and extremely tender to touch. Which lab finding might be normal in this pt? How should you get around this?

Answer 3

Gout
Serum uric acid level can be normal during a flare/acute attack
Test it 2 weeks after the attack

Question 4

A 68 yo female presents complaining of acute onset swelling in her 2nd PIP joint that is very painful. What is the best way diagnostic for her suspected condition?

Answer 4

Gout

Fluid culture & microscope analysis of synovial fluid for MSU crystals

Question 5

A 65 yo male presents complaining of rapid onset, severe pain in his 1st MTP joint. X-ray shows soft tissue swelling without erosion. What treatment do you recommend?

Answer 5

Gout
NSAIDs
Colchicine
Steroids
Urate Lowering Therapy (Allopurinol, Febuxostat)
Lifestyle/Diet changes
Pegloticase

Question 6

What are the 3 C’s to diagnose gout?

Answer 6

Cell count
Culture
Crystal analysis

Question 7

What lifestyle/dietary changes should you recommend to a pt you have just diagnosed with gout?

Answer 7

Avoid shellfish, small fish, organ meat, beer, high fructose corn syrup, and sugar
Low-fat dairy & coffee are good
Portion control/weight loss
Mediterranean style diet

Question 8

A pt presents because he feels his gout isn’t being well controlled. He usually has 3-4 flares/yr for the past 5 years, and within the past year he has developed tophi on his feet. What could you recommend for this pt? What should be his target sUA?

Answer 8

Urate Lowering Therapy

sUA goal

Question 9

A pt present with signs and symptoms consistent with gout. You perform synovial fluid analysis, and under the microscope the crystals appear rhomboid/rectangular shaped and they have weak positive birefringence. Analysis also shows a lot of neutrophils. Does this change your diagnosis? What is the pathophys of this Dz?

Answer 9

Pseudogout!

Calcium pyrophosphate crystals cause gout-like sx

Question 10

A pt presents with a swollen, very painful elbow joint. X-ray shows punctate linear crystal deposits in the menisci & cartilage along with chondrocalcinosis. What treatment should you recommend?

Answer 10

Pseudogout
No treatment
Intra-articular corticosteroids are acute Tx
NSAIDs moderate sx
Colchicine may help