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Rheumatology YR3 > Crystal arthropathies > Flashcards

Crystal arthropathies Flashcards

1
Q

What is gout?

A
  • Inflammatory arthiritis related to hyperuricaemia
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2
Q

Joints affected in gout

A

Acute gout can affect 1 or more joints but most commonly involves the 1st metatarsophalangeal joint (big toe aka podagra)

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3
Q

Pathophysiology of gout

A

Deposition of monosodium urate crystals that accumulate in joints and soft tissues, resulting:
* Acute and chronic arthirits
* Soft tissue masses called tophi
* Urate nephropathy
* Uric acid nephrolithiasis

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4
Q

What is common after initial flare of gout?

A

Second flare up occurs in 60% of patients within 1 yr and 78% within 2yrs of initial attack

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5
Q

Management of gout overall, non specific

A
  • Treat acute attacks
  • Prevent recurrent disease - long term reduction in uric acid levels by meds and lifestyle
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6
Q

Risk of gout

A

Associated with high risk of CVD

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7
Q

Risk factors of gout - non modifiable

A
  • Age older than 40
  • Male
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8
Q

Modifiable risk factors for gout

A
  • Increased purine intake (urate is metabolite of purines) eg red meat and seafood
  • Alcohol intake (esp beer)
  • High fructose intaje
  • Obesity
  • Congestive HF
  • Coronary artery disease
  • Dyslipidaemia
  • Renal disease - CKD
  • Organ transplant
  • HTN
  • Smoking
  • Diabetes mellitus
  • Urate elevating medications eg thiazide and loop diuretics
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9
Q

Investigations for gout

A

Joint aspiration - rules out infection, can see crystals

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10
Q

Treatment gout - conservative

A
  • Maintain optimal weight
  • Regular exercise
  • Diet modification - reduce purine rich foods
  • Reduce alcohol consumption - beer and liqour
  • Smoking cessation
  • Maintain fluid intake and avoid dehydration
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11
Q

Appearance of gout crystals under microscope

A

Needle shaped crystals which are yellow - negatively birefringent through polarised light

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12
Q

First line pharmacological managaement for gout acutely

A
  • NSAIDs - often naproxen
  • Oral/IM steroids
  • Colchicine
  • Recombinant uricase - but often people have reaction to this
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13
Q

What scenario can we not give naproxen?

A
  • AKI/CKD
  • Bleeding/stomach ulcers
  • HF
  • Asthma - sometimes react

If cannot have - often have steroids

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14
Q

Side effects of colchicine

A
  • GI side effects - nausea, vomitting
  • Pancytopenia
  • Need to decrease dose in CKD
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15
Q

Who do we need to take precautions giving steroids to?

A
  • Diabetic patients - increases BMs
  • HF
  • Bleeding
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16
Q

Examination findings of someone with gout

A
  • Hot tender joint - 1st MTP usually but cna be polyarticualr
  • Tophi
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17
Q

How does colchicine work?

A

Stops neutrophils adhering to endothelium
Decreases inflammation

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18
Q

What are tophi?

A
  • Depositions of urate crystals in soft tissue
  • Often found in fingers and ear around helix area
  • Sign of chronic gout
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19
Q

Long term pharmacological therapy for chronic gout

A

Urate lowering therapy eg allopurinol and febuxostat (F in HF or if allo not working)
These are commenced usually 2 weeks after flare up

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20
Q

What is intercritical gout?

A

Between attacks of gout - had a flare but better now

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21
Q

How do allopurinol and febuxostat work?

A
  • Xanthine oxidase inhibitors
  • Reduce urate formation
22
Q

Less commonly used pahrmacological management of chronic gout

A
  • Benzbromarone
  • Sulfinpyrazone
  • Less used as more side effects
  • But these increase renal excretion of uric acid
23
Q

Aim of urate lowering medications

A

Aim to reduce serum uric acid to less than 360 micromol/L

24
Q

When should pharmacological management of acute gout be started?

A

Begin within 24hrs of flare up as it is highly effective then

25
Q

what happens if a pt has hyperuricaemia with no symptoms?

A

No treatment is needed

26
Q

What type of crystals are found in aspirate for gout?

A

Monosodium urate crystals - only in gout, diagnostic

27
Q

Diagnosis of gout needs..

A

Joint aspiration

28
Q

Differential diagnosis of gout

A
  • Septic arthirits - monoarthiritis you should always consider
  • Pseudogout
29
Q

What crystals are present in pseudogout?

A

Calcium pyrophosphate crystals

30
Q

Who does psuedogout most commonly affect?

A

Older women with OA

31
Q

How does gout present?

A
  • Single hot joint
32
Q

Why does gout affect males more than pre-menopausal females?

A

Oestrogen increases excretion of uric acid in urine

33
Q

Usual resolution of acute gout

A
  • Flare up resolves within 3-10 days
  • Can reoccur and spread to other joints
  • Can get rebound gout if stop treatment and gout is bad again - not fully treated
34
Q

Uric acid blood test results during gout

A
  • Can be high - shows gout
  • Can be low - as can be consumed when being deposited in joint spaces
  • So cannot really use as a measure
35
Q

Whats podagra?

A

Gout of 1st MTP

36
Q

X-ray appearance of gout

A

Punched out regions at edges of joints - erosions
Sclerosis often around these lesions
Like caterpillar eating a leaf

37
Q

What can we not give allopurinol alongiside and why?

A
  • Azathioprine
  • Allopurinol inhibits xanthine oxidase which breaks down azathioprine
  • Can overdose on azathioprine
38
Q

What can xanthine oxidase’s trigger so what must we do?

A
  • Gout flare up - destabilses crystals as lowers serum urate so crystals break down
  • Must take NSAID/colchicine for 6 months when starting these
39
Q

Indications for allopurinol (long term serum urate reducing medications)

A
  • Tophi
  • Frequent attacks
  • Urate caused kidney damage CKD
  • Erosive joint disease
40
Q

Side effect of allopurinol

A
  • Need to decrease dose in CKD
  • Rash
  • Allopurinol hypersensitivity syndrome
41
Q

What is allopurinol hypersensitivity syndrome, how does it present?

A
  • Fever
  • Rash
  • Kidney failure
  • Leukocytosis
  • Eosinophilia
  • Abnormal LFTs
42
Q

Risk factors for pseudogout

A
  • Hyperparathyroidism
  • Familial hypocalciuric hypercalcaemia
  • Haemochromatosis
  • Hypothyroidism
  • Hypomagnesia
  • Hypophosphataemia
  • Gout
  • Ageing
  • Amyloidosis
  • Trauma
  • Neuropathic joints
43
Q

Radiological sign of pseudogout

A
  • Milwaukee shoulder
  • Chondrocalcinosis
44
Q

What is Milwaukee shoulder?

A

Depositions of crystals within synovium - synovial space no longer black, filled with crystals

45
Q

What is chondrocalcinosis?

A

Calcification of cartilage between joints - calcium pyrophosphate deposition

46
Q

Pseudogout vs gout under microscope

A
  • Gout - needle shaped crystals (negative birefingent)
  • Pseudogout - more square shaped (rhomboid and positive birefingent)
47
Q

Other than monosodium urate crystals in joint aspirate/tophi, other critria for gout diagnosis

A

Six or more of the following apply:
* More than one attack of acute arthritis.
* Maximum inflammation developed within 1 day.
* Monoarthritis attack, redness observed over joints.
* First metatarsophalangeal joint painful or swollen.
* Unilateral first metatarsophalangeal joint attack.
* Unilateral tarsal joint attack.
* Tophus (confirmed or suspected).
* Hyperuricaemia.
* Asymmetrical swelling within a joint on X-ray film.
* Subcortical cyst without erosions on X-ray film.
* Joint culture negative for organism during attack.

48
Q

Where are tophi commonly located?

A

Extensors - eg elbow, knee, achilles tendon or sometimes behind ear

49
Q

When is urate lowering therapy recommended to be commenced?

A
  • If have 2 or more attacks per year
  • If renal disease
  • Tophi
  • Uric acid renal stones
  • Prophylaxis if on diuretics or cytotoxics
50
Q
A

Rheumatology YR3 (18 decks)

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