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Medicine II: Rheumatology > Crystal Arthropathies > Flashcards

Crystal Arthropathies Flashcards

1
Q

Gout

A

Gout is the most common form of inflammatory arthritis. Occurs when uric acid builds up in blood and causes inflammation in the joints. Disease of URATE BURDEN. Insufficient excretion kinetics seen in primary gout (shift to the right).

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2
Q

Etiology of Gout

A

The incidence of gout has doubled in past 3 decades. Onset of symptoms in men: 40s-50s; in women : 60s-70s

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3
Q

Epidemiology of Gout (Uric Acid Production)

A

Xanthine oxidase catalyzes the final steps in the conversion of purines to uric acid. Once produced, uric acid is predominantly handled by the kidneys. (~8%-12% excreted); (~90% reabsorbed).

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4
Q

Acute vs Chronic Gout

A

Acute gout is a painful condition that often affects only one joint; Chronic gout is repeated episodes of pain and inflammation. More than one joint may be affected.

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5
Q

Clinical Features of Acute Gout

A

Symptoms of acute gout: Only one or a few joints are affected. The big toe, knee, or ankle joints are most often affected. The pain starts suddenly, often during the night. Pain is often described as throbbing, crushing, or excruciating.The joint appears warm and red. It is usually very tender and swollen.

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6
Q

Management of Gout

A

Controlling pain and inflammation. Reducing urate burden.
Acute Gout: NSAIDS, colchicine, and gluccocorticoids.
Anti-inflammatory prophylaxis: NSAIDS and Colchicine.
Reducing Urate Burden: Allupurinol, Feduxostat, Probenecid, and Pegioticase.

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7
Q

Dx of Gout

A
  1. Synovial fluid crystal analysis is the gold standard, Classic history and physical examination (if recurrent), Hyperuricemia (not always elevated), Response to colchicine (inconsistent).
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8
Q

CPPD/pseudogout

A

CPPD crystals release may involve “enzymatic stripping” allowing previously concealed crystal deposits into the joint. Crystals are phagocytosed by synovial lining cells.

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9
Q

Epidemiology of CPPD/pseudogout

A

Most common in fibrocartilage: knee, wrist triangular ligament, and symphysis pubis. Rare before age 50. Prevalence: 30%-50% in people over 75 years of age. More common in women (2-7x more common).

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10
Q

Clinical features of CPPD/pseudogout

A

Acute Pseudogout (more common in pts. with chondrocalcinosis). Chronic pyrophosphate arthropathy is a subset of OA CPPD crystals: process marker for articular insult.

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11
Q

Acute CPPD/pseudogout

A

90% monoarticular; usually the knee. Also seen in wrists, shoulder, ankle and elbows.

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12
Q

Ddx of CPPD/pseudogout

A

Synovial fluid crystal analysis, X-ray

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13
Q

Apatite/oxalate deposit disease associations

A

A. Sporadic / Aging (90%): i. Calcific tendinitis
ii. OA (asymptomatic), iii. Milwaukee shoulder.

B. Diseases (10%): i. Hyperparathyroidism, Sarcoidosis, iii. Chronic renal Failure (dialysis), iv. CTDs: SLE, scleroderma, dermatomyositis, v. Tumoral Calcinosis

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14
Q

Etiology of Apatite/oxalate deposit disease

A

Basic Calcium Arthropothy.

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15
Q

Calcium Pyrophosphate Crystals

A

PSEUDOGOUT

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16
Q

Monosodium Urate Crystals

A

GOUT

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17
Q

Clinical features of Apatite/oxalate deposit disease

A

Milwaukee Shoulder and Calcific Tendonitis

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18
Q

Management of Apatite/oxalate deposit disease

A

NSAIDS

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19
Q

Ddx of Apatite/oxalate deposit disease

A

Milwaukee Shoulder: SF- mononuclear with blood.

20
Q

Urate Excretion Kinetics of Gouty vs Nongouty Patients

A

Insufficient excretion kinetics seen in primary gout. The cause of 90% of primary hyperuricemia and gout. 30% less uric acid excreted in gouty vs nongouty patients.

21
Q

Consequences of Expanded Urate Pools

A

Asymptomatic hyperuricemia, Hypertension, kidney & heart disease, Renal Manifestations, Gouty arthritis, Urate tophi

22
Q

Common Sites of Acute Flares in Men

A

1st MTP (eventually affected in ~ 90% of individuals with gout), Knee, Subtalar, Midfoot

23
Q

Common Sites of Acute Flares in Women

A

Olecranon Bursa, Elbow, Wrist, Fingers

24
Q

Stages of Gout:

A
  1. Asymptomatic Hyperuricemia, 2. Acute Gout with Intercritical Periods, 3. Advanced Gout
25
Q

Advanced Gout (If uncontrolled hyperuricemia continues):

A

Total tissue urate stores increase

Deposition in joints may progress to chronic arthritis

26
Q

Advanced Gout (with chronic arthritis):

A

Involved joints persistently uncomfortable, stiff, and swollen, Pain intensity often less than acute flares, May mimic rheumatoid or psoriatic arthritis, Acute flares may still occur, Radiographic changes are common

27
Q

Urate Icing

A

Deposition of layer of echogenic material on the hyaline cartilage. Tophaceous material can be seen with US within the joint capsule.

28
Q

Dual-Energy Computerized Tomography

A

Distinguishes urate from calcium containing crystal structures. Estimates total body urate burden. Can detect crystal formers among asymtpomatic hyperuricemics. EXPENSIVE AND HAS HIGH RADIOGRAPHIC EXPOSURE

29
Q

Which comes first: CPPD Crystals or Osteoarthritis (OA)?

A

CPPD crystals in a/w OA resulted in more severe OA. CPPD crystals injected into normal joints caused no damage.

30
Q

Secondary Causes of Pyrophosphate Arthropathy

A

Hyperparathyroidism, Hemochromatosis, Hemosiderosis, Ochronosis, Aging, Amyloidosis, Hypomagnesemia, Hypophosphatasia, Hypothyroidism, Gout, Neuropathic joints.

31
Q

Acute Pseudogout

A

Monoarticular (90%). Usually knee. Also seen in the wrist, shoulder, ankle, and elbows. Predominantly in elderly women. Usually resolves in 1-3 weeks.

32
Q

Calcific Tendinitis

A

In the shoulder in over 70%. Acute. Local inflammation. Symptoms secondary to rupture of calcific deposits into adjacent periarticular tissues. TX- NSAIDs, CS injection controversial.

33
Q

Milwaukee Shoulder (‘Bloody Old Shoulder’)

A

90% women, age> 70. Several week/month history of joint inflammation & loss of ROM (usually shoulder). SF: mononuclear & blood. Tx: NSAIDs, CS injection (partial benefit). Conservative secondary to limited duration.

34
Q

Onset of gout is earlier in ______________

A

men than in women

35
Q

Most gout is caused by a relative ____________ of urate by the kidneys.

A

underexcretion

36
Q

T/F: The clinical manifestations of gout differ between men and women

A

True

37
Q

Acute gout

A

Characterized by rapid escalation of excruciating pain, usually in a single joint with loss of function of that joint for 3-7 days.

38
Q

Chronic gout

A

A destructive polyarthritis involving any peripheral joint. This is also called gouty arthritis. This condition can lead to joint damage and loss of motion in the joints. People with chronic gout will have joint pain and other symptoms most of the time.

39
Q

MSU crystals are _______ shaped with _________ birefringence

A

needle; negative

40
Q

Calcific tendinitis and Milwaukee shoulder are forms of _____________________

A

basic calcium deposition and can be very destructive.

41
Q

Tophi

A

Tophi are lumps below the skin around joints or other places such as the finger tips and ears. Tophi can develop after a person has had gout for many years. These lumps may drain chalky material.

42
Q

Gout Tx:

A
  1. NSAIDS.
  2. Colchicine (helps reduce pain, swelling, and inflammation).
  3. Corticosteroids (such as prednisone) can also be very effective in relieving pain.
43
Q

Dx Gout with Imaging

A
  1. Plain Radiographs- Useful to rule out fracture or infection in early, acute disease. Insensitive for gouty changes until after 5-8 yrs.
  2. Ultrasound- Easily performed in clinic. Highly sensitive and specific.
  3. Dual-Energy CT- Expensive with radiation exposure. Ability to quantitate urate burden.
44
Q

Consequences of Expanded Urate Pool

A

a. renal manifestations
b. gouty arthritis
c. urate tophi
d. asymptomatic hyperuricemia
e. HTN, Kidney and Heart DZ

45
Q

What is an important pharmaceutical target for gout?

A

Xanthine Oxidase

46
Q

Stages of Gout

A
  1. asymptomatic hyperuricemia
  2. acute gout with intercritical periods
  3. advanced gout
47
Q

Sites of acute flares of Gout (Men vs Women)

A

Can occur in bursae, tendons and joints.
In MEN: 1st MCP, knee, subtalar and midfoot.
In WOMEN olecranon bursa, elbow, writs, fingers and knee.

Medicine II: Rheumatology (9 decks)

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