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Locomotor 2 > Crystal Arthropathies > Flashcards

Crystal Arthropathies Flashcards

1
Q

What is gout

A

Common disorder of uric acid metabolism

Monosodium urate crystals get deposited in soft tissues

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2
Q

What does the variation of gout depend on

A

Variation reflects environmental, dietary and genetic influences

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3
Q

how much of the population does gout affect

A

1% of population

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4
Q

Who is gout common in

A

men and men earlier than women

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5
Q

What is the main crystals that are formed in gout

A

Monosodium urate crystals

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6
Q

What happens if gout is untreated

A

Joint destruction

Renal damage - most of the monosodium urate crystals are excreted via the kidney therefore higher risk of kidney stones and thus kidney damage

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7
Q

describe attacks of gout

A
  • may have gout attacks and then may never get another one or you may a few months later
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8
Q

Why are men more at risk of developing gout

A

Men are more at risk of developing gout as serum uric acid levels are higher to begin with, urinci acid levels start to increase at the time of puberty in men whereas in women it doesn’t start to develop and raise until menopause

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9
Q

How long does uric acid have to increase before the onset of gout

A

Uric acid levels raised for 20 years before onset of gout

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10
Q

describe the pathophysiology of gout

A

Presence of urate crystals in the synovial fluid are not enough to cause an attack as they are inert as they are coated with serum proteins already present in the synovial fluid

Get a sudden increase in the number of crystals that are forming and the body is not able to respond by coating the crystals with the serum proteins and thus there are some uncoated cryrstals in the joint which trigger the attack

Crystals can be uptake by neutrophils, pierce the neutrophil and cause it to die, cell releases the proteins, proteins call in more white blood cells and cause inflammation and pain, proteins lower pH making it possible for more crystals to form

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11
Q

When are the crystals in gout not harmful

A

Presence Clumps (microtophi) of highly negatively charged monosodium urate crystals normally coated with serum proteins are inert and are not enough to cause an attack as they are inert as they are coated with serum proteins already present in the synovial fluid

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12
Q

when is gout unlikely to start before the age of

A

Gout unlikely before 30 years of age

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13
Q

what joint is gout more likely to affect

A

Podagra (inflammation of 1st MTP joint)
50% of cases
- less blood supply and colder so already has a lower pH

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14
Q

when does gout begin

A

Begins suddenly and reach maximum intensity with 8-12 hours

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15
Q

What joints does gout affect

A

Acute monoarticular
- 90% of cases

Small lower extremity joints

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16
Q

What patients characteristic for this with gout

A
  • male
  • high uric acid
  • overweight
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17
Q

What is the joint must commonly affected by gout

A

1st metatarsal phalagenal joint

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18
Q

what is the largest joint affected by gout

A

knee

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19
Q

what over areas of the body are affected by gout

A
  • renal damage

- tophi in cartilage

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20
Q

describe what the symptoms of gout

A

Joint

  • Red
  • Hot
  • Exquisitely tender
  • Pain starts acutely and usually at night
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21
Q

how long does gout take to resolve itself

A

Untreated 1st attacks resolve spontaneously in less than 2 weeks

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22
Q

gout has …

A

intermittent cycles

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23
Q

every time you have a gout flare…

A
  • become more painful
  • last longer
  • until eventually the pain is there all the time due to the damage to the bone and joint
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24
Q

What happens if gout is untreated

A

Attacks become polyarticular

More proximal and upper extremity joints involved

Attacks more frequent and last longer

Chronic polyarticular arthritis almost symmetrical

Can affect other synovial structures

rat bite erosions - were the joint capsule is inserting, these are on the main shaft

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25
Q

what happens in an acute gout attack

A
  • phagocytosis of crystals
  • cell swelling and inflammationsome activation
  • cytokine production and vasodilation
  • neutrophil and monocytes influx
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26
Q

What happens in chronic tophaceous gout

A
  • neutrophil death by NETosis
  • packaging of MSU crystals
  • inactivation of inflammatory cytokines
  • resolution of inflammation
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27
Q

What is tophi

A

Urate crystals in soft tissues

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28
Q

how many patients with gout have tophi

A

Develop in 50% of patients with untreated gout

Develop after 10 years

usually patients who are untreated

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29
Q

describe the histology of tophi

A

Foreign body-type giant cell reaction to the deposited crystals

The crystalline nature of this material is not obvious in formalin-fixed specimen

tissue macrophages around the central core and lymphocytes further out

30
Q

What are the causes of a gout attack

A

uric acid is an end stage by-product of purine metabolism

  • and humans remove uric acid by renal excretion(70%) and faeces (30%)
  • when there is insufficient excretion, which is the cause of 90% of the cases of gout, this can lead to urate levels building up
  • When excretion insufficient to maintain serum urate levels below saturation (6.8mg/dL) hyperuricemia may develop
31
Q

what is the cause of 90% of cases of gout attack

A

Overproduction 10% of cases

Under excretion 90% of cases

32
Q

what the risk factors for gout

A
  • male gender
  • age
  • obesity
  • ethnicitiy
  • polymorphism
  • kidney disease
  • overconsumption of foots high in purines - beef, pork, lamb, seafood, beer, alcoholic beverages
33
Q

what can lead to under excretion of uric acid

A
  • renal insufficiency
  • dehydration
  • thiazide diuretics
34
Q

what are the 11 or more variables that are used by GPs to diagnose gout

A
  1. more than 1 attack of acute arthritis
    2, maximum inflammation developed within 1 day
  2. mono arthritis attack
  3. redness observed over joints
  4. first MTP joint painful or swollen
  5. unilateral first MTP joint attack
  6. unilateral tarsal joint attack
  7. Tophus
  8. hyperuricaemia
  9. asymmetrical swelling within a joint on X ray
  10. subcortical cysts without erosions on X ray
  • have to have greater than or equal to 6 out of a 11 for probable gout
  • Urate crystals during acute = definitive gout
  • > 4 to <8 = uncertain synovial fluid analysis

-

35
Q

what symptom is definitive gout

A

Urate crystals during acute = definitive gout

36
Q

what if the 11 or more variables used for gout score is 4 or less what can the condition be

A

RA

pseudogout

psoriatic arthritis

septic arthritis

reactive arthritis

37
Q

what are out factors that can highlight that it can be gout

A

Male

Hypertension/other cardiovascular disease

Serum uric acid level more than 5.88mg/dL

38
Q

what does the synovial fluid look like if you have gout

A

Inflammatory

WBC count greater than 2000/μL and possibly greater than 50,000/μL

Predominance of polymorphonuclear neutrophils (PMNs)

Polarizing light
- Urate crystals needle like and high negatively birefringent

39
Q

How do you diagnose gout using serum uric acid

A

Presence of hyperuricemia is not diagnostic

  • 5-8% of population have elevated serum uric acid levels (>7mg/dL)
  • Only 5-20% of patients with hyperuricemia develop gout
  • If higher than 11mg/dL should be treated
40
Q

what level of serum uric acid should you be treated for gout

A
  • If higher than 11mg/dL should be treated
41
Q

How can you diagnose gout using imaging

A

Doppler ultrasound
- measure the blood flow/ soft tissue swelling

X rays can also be used

  • maintenance of joint space
  • erosion outside joint capsule
  • erosions have overhanging edges - rat bite
42
Q

what is a dual energy computed tomography able to detect

A
  • Able to detect uric acid crystal deposits in all gout patients with late stage gout
  • able to detect uric acid crystals in tophi
  • Able to detect uric acid crystal deposits in 64% of patients with early stage gout

Not as sensitive as needle biopsy

43
Q

What can a dual energy computed tomography be used for clinically

A

Can measure MSU volume

Changes in actual MSU following treatment

Predict gout flare

44
Q

What is joint damage a feature of (rat bite)

A

Joint damage is a feature of all erosive/inflammatory arthropathies
- osteoclasts erode the bone- get more of these where you have the crystals

45
Q

How are bony erosions/rat bites caused

A

MSU crystals surrounded by granulomatous tissue reaction

Produce pro-inflammatory cytokines (IL1, TNF, IL6)

Stimulate osteoclasts (RANKL) - these cause the reabsorption of bone, they accumulate underneath the crystals

46
Q

tophaceous deposits can lead to…

A

bone erosion

47
Q

what treatment is sued for gout

A

NSAIDs

  • Start with highest dose for 2-3 days
  • Taper down over 2 weeks
  • Gout symptoms should be absent for 2 days before treatment stopped

Colchicine

  • Now 2nd line because of narrow therapeutic window and risk of toxicity
  • stops neutrophils and macrophages dividing
  • mitotic inhibitor

Corticosteroids
- For those that can’t use NSAID or colchicine

48
Q

What biologicals can be used for gout

A

IL1 biologicals
- Rilonacept, canakinumab, anakinra

  • Reduces length of attack and reoccurrences
  • Used for patients who have severe and frequent flares
  • expensive therefore not first line
49
Q

what lifestyle advice can you give someone with gout

A

diet advice

- low purine diet = reducing red meat, oily fish, yeast (beer), fish, fruits such as avocado

50
Q

what food would you recommend for a low purine diet

A
  • coffee
  • cheese
  • eggs
  • bread
  • butter
  • vegetables
  • milk
51
Q

What is the treatment of chronic gout and how do they work

A

Allopurinol

  • Blocks xanthine oxidase
  • Reduces generation of uric acid

Probenecid

  • Uricosuric
  • Increases uric acid excretion
  • Fewer significant adverse effects than allopurinol

Rasburicase
- Catalyses conversion of uric acid to allantoin which is more soluble

  • these are all done once the attack as died down
52
Q

what is the aim of the long term management of gout

A

Lowering of uric acid levels

53
Q

what is pseudogout

A
  • this is deposition of calcium pyrophosphate in and around joint
54
Q

what is pseudogout sometimes known as

A

Calcium pyrophosphate deposition disease (CPDD

55
Q

what joints do psuedogout affect

A
  • need a joint with cartilage present in

- for example the knee

56
Q

describe characteristics of pseudogout

A

Metabolic arthropathy

Chondrocalcinosis

57
Q

What is chondrocalcinosis

A

Chondrocalcinosis is the deposition of CPPD crystals into fibrous or hyaline cartilage.

58
Q

what disease is pseudogout associated with

A

Osteoarthritis

  • they already have breakdown of cartilage and exposure of the bone
  • therefore they have a higher prevalence of having calcium salts deposited in the joints themselves
59
Q

how many people over the age of 85 have chondrocalcinosis

A

Around 50% of people over 85 years have evidence of chondrocalcinosis

60
Q

what types are the two different types of findings with pseudogout

A

Pseudo-osteoarthritis (50% of cases) with osteophytes and soft tissue calcification on radiographs
Or

Asymptomatic where only radiographic findings and no other symptoms

61
Q

describe the pathophysiology of pseudogout

A

Release of CPPD crystals into joint space followed by phagocytosis of crystals by monocyte-macrophages or neutrophils which then release cytokines and cause inflammation

62
Q

what joint is commonly affected by pseudogout

A

Knee is most commonly affected joint but can affect any joint

63
Q

What can trigger an attack of pseudogout

A

Trauma

Rapid reduction of serum calcium conc

64
Q

What does the synovial fluid

A
  • not as shiny as in gout
  • Mild to moderate -inflammation 10,000-50,000 WBCs/μL 90% neutrophils (PMNs)
  • Rhomboid shaped weakly birefringent crystals
  • milder attack as they don’t cause as many neutrophils to burst
65
Q

How do you diagnose psuedogout

A

Ultrasound may be helpful in diagnosing

66
Q

what would the ultrasound show in pseudogout

A

Calcification within soft tissue

Calcification within the articular cartilage
- Parallel with condyle

67
Q

what could does pseudogout show in radiographs

A

Chondrocalcinosis of articular disc and atypical OA of hands

Often OA in same or neighbouring joints

68
Q

what is the treatment for pseudogout

A

Intra-articular corticosteroids

NSAIDs

69
Q

where can you find cholesterol crystals

A

Cholesterol crystals

Rare finding in some cases of rheumatoid arthritis synovial fluid

70
Q

describe the structure of cholesterol crystals

A

Cholesterol crystals have a plate like structure often notched

71
Q

What is cholesterol crystals caused by

A

Defective drainage of synovial fluid back into venous system

Local destruction

Increased permeability of synovial membrane to LDL and HDL

Intraarticular bleeding

72
Q

cholesterol crystals are..

A

difficult to clear

- perpetuation of the arthritis

Locomotor 2 (30 decks)

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