Crystal arthritis Flashcards
Pain and swelling in big toe
Podagra
Triggering events in gout attack
Trauma
Dietary/OH excess
Diuretic use/change
Risk of gout:
Age, family history, obesity, diabetes, HTN, OH use, acute illness, surgery
Calcium pyrophosphase (CPP) crystals are deposited in
articular cartilage
menisci, synovium, periarticular tissues
May be used to treat CHRONIC inflammatory CPPD
Hydroxychloroquine, Methotrexate if NSAIDs or Colchisine inadequate
Intercritical period in gout is
Asymptomatic periods
How likely is another acute attack in the first year after a first attack?
60%
Allopurinol side effects
Allopurinol hypersensitivity, NVD, marrow suppression, hepatitis, fever, vasculitis, alopecia
CPPD is associated with
aging, hyperparathyroidism, hemochromatosis, trauma, hypophos/hypomag
Asymptomatic hyperuricemia begins at
Puberty for men
Menopause for women
Clinical presentation of CPPD
Usually mostly asymptomatic
Asymptomatic hyperuricemia is associated with
hypertension, hyperglycemia, obesity, hyperlipidemia, CV disease
Tophi =
Aggregated MSU crystals
Usually located on ulnar surface of forearms, tendons, olecranon, ear, joints
Options for acute gout therapy
colchicine
NSAID
corticosteroids
joint injection if no infection
Febuxostate
non-competitive xanthine oxidase inhibitor
Joints affected by Acute Gout
MTP, instep, ankles, knees, prepaterllar/olecranon bursae
Acute gout is usually ______articular
MONOarticular
Allopurinal, Febuxostate are…
Xanthine oxidase inhibitors
Stop purine metabolism, uric acid doesn’t form
It is possible for people in an acute attack to have a normal uric acid level
True - 50% will have normal level
Acute CPP (pseudogout) presents with
acute/subacute arthritis for several days, monoarthritis (knees, wrists), podagra UNcommon, may follow surg/trauma/illness/diuresis
Characteristic Radiology finding of Tophi/Chronic gout
Punched out erosions surrounded by radiodensity
Joint space preservation, normal mineralization
Late disease: punched out lesions with overhanging edges
Chronic/tophaceous gout is usually _____articular
POLYarticular
Side effects include cardiovascular (MI, CVA), elevated liver transaminases, gout flare
Febuxostat
Chronic Kidney Disease is probably d/t
precipitation of uric acid crystals
hypertension
diabetes
Raising SUA induces glom HTN, fibrosis
Lowering SUA may slow CKD progression
Presumptive Gout Diagnosis
Rapid, severe pain
Pain, erythema, swelling
Hyperuricemia
Chronic Inflammatory CPPD presents as
polyarticular, symmetric arthritis of small joints in hands/feet
What happens when phagocytes ingest crystals?
Lysis and inflammatory response
mimics DJD
OA with CPP clinical presentation
Risk for kidney stones is _______ to uric acid level (SUA)
proportional
Colchicine
Inhibits microtubule formation (turn off cytokine cascade, inhibit NLRP3 assembly)
What is released with macrophace lysis?
IL-1, IL-18, cytokines
Followed by neutrophil infiltration
Management of Gout
Baseline: Ed, diet, lifestyle
Look for secondary hyperuricemia causes
Acute therapy (colchicine, NSAID, corticosteroids, joint injection if no infection)
Diagnosis of CPPD
Weakly birefringent, Positive birefringents (aligned blue calcium) Rhomboid crystals, intracellular
Things that can lead to hyperuricemia
High purine diet
Alcohol (beer highest)
Fructose
cell death
ATP -> AMP -> Uric acid
XOI alternative
Probenecid
Diagnosis of Gout
Demonstrate needle shaped crystal inside cell, Negatively birefringent, Parallel-yellow (plane of polarization)
(If the crystal is perpendicular to plane it will be blue)
CPPD radiology features
Cartilage calcification (deposition into fibrous/hyaline calcium)
Uniform joint space loss
No erosions
Knees > Hands > Symphasis
Uricosuric added to XOI if
XOI not tolerated, under 60, normal renal function, no history of stones, more than 2 attacks/year,
