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Locomotor Y2 > Crystal arthropathies > Flashcards

Crystal arthropathies Flashcards

1
Q

What causes gout?

A

Abnormal metabolism of Uric acid which causes Monosodium urate crystals to be deposited in soft tissues

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2
Q

What happens if gout is untreated?

A

Joint destruction

Renal damage

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3
Q

For how long is uric acid elevated before the onset of gout?

A

20 years

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4
Q

In which sex is gout most common in and why?

A

Men
Uric acid in men rise at puberty and peak age of onset is 4th -6th decade
In women uric acid rises at menopause peak age of onset is 6th-8th decade.

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5
Q

What is the pathophysiology of gout?

A

Clumps of negatively charged monosodium urate crystals coated with serum proteins are chemically inactive

A gout attack is triggered by uncoated crystals or a sudden large change in concentration

White blood cells migrate to the site of the monosodium cyrstal to remove the uric acid.

The crystals pop the cell

The cell releases proteins

The proteins attarct more white blood cells and cause inflammation and pain

The proteins lower the pH so more uric acid crystals form

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6
Q

At which age is gout most likely to occur?

A

after 30 years

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7
Q

Which type of joints in the body is gout most likley to affect?

A

Small joints in the lower extremity

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8
Q

Which joint in particular is infected with gout 50% of the time? What is it called when this joint is affected?

A

1st MTP joint

(first metatarsal joint on the big toe)

Podagra

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9
Q

When does a gout infection reach its maximum intensity?

A

8-15 hours

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10
Q

What is the name given for when the knew joint is infected with gout?

A

Gonagra

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11
Q

State 4 other complications of gout

A

1- Renal damage
2- Tophi in cartilage
3- Gout soteoarthropathy
4- Soft tissue tophi on hands

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12
Q

If someone’s joint is infected with gout, how would they describe it?

A

Red
Hot
Exquisitely tender
Pain starts acutely and usually at night

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13
Q

How long does the first gout attack last? How many joints are usually affected?

A

under 2 weeks

One joint is usually affected

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14
Q

What is the prognosis of a patient who has untreated gout?

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

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15
Q

What are Tophi?

How long does it take for them to develop?

A

Permanent deposits of urate crystals which form on soft tissue. Cuased by untreated gout

Develop after 10 years

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16
Q

Describe how insufficient excretion of urine can increase the chances of contracting gout?

A

Uric acid is produced by purine metabolism

Humans remove uric acid via renal excretion and faeces

When uric acid excretion is not enough to maintain the level of urate in the body (serum) below the point of saturation (6.8 mg/dL) hyperuricemia develops

90% of patients have excess urate stores from insufficient excretion in urine

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17
Q

List the different causes for gout

A

Elevated purine sources (increased consumption of purines):

  • Increased catabolism of purines
  • Tumor lysis syndrome
  • Diet- red meat, sea food, beer, drinks with fructose

Decreased clearance of uric acid:

  • Drugs (aspririn and HTZ)
  • Fructose
  • Kidney disease
  • Genetic predisposition

Disorders that can cause hyperuricemia:

  • Joint inflammation
  • Kidney and bladder stones
  • Metabolic syndrome
  • CV disease

Under-excretion of uric acid

  • Renal insufficiency
  • Dehydration
  • Diuretics (Thiazide)
18
Q

List 5 risk factors for gout

A 
Male
Age <30
Obesity 
Kidney disease 
Ethnicity (pacific islanders
Genetics
19
Q

How is gout diagnosed?

A

11 or more variables that can be used by GPs to diagnose gout
Having 6 or more of the variables means you have a probability of having gout

> 4 to <8 = uncertain synovial fluid analysis

Less than 4 not gout

20
Q

What sign can be used to definitely confirm gout?

A

Urate crystals during acute attack = definitive gout

21
Q

List 4 differential diagnosis for gout?

A

RA, pseudogout, psoriatic arthritis, septic arthritis, reactive arthritis

22
Q

When assessing synovial fluid in the case of gout, what are you looking for to to confirm the diagnosis?

A

Inflammatory cells

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

Predominance of polymorphonuclear neutrophils (PMNs)

use Polarizing light to find Urate crystals needle like and high negatively birefringent

23
Q

Is the presence of hyperuricemia diagnostic and why?

A

No it is not

Only 5-20% of patients with hyperuricemia develop gout

24
Q

Which X ray findings indicate gout?

A

Erosions have overhanging edges- Rat bite

Erosion outside joint capsule

Maintenance of joint space

25
Q

Which ultrasound findings indicate gout?

A

Soft tissue swelling / increased blood flow

erosion

26
Q

Out side of ultrasound and Xrays, which other methods can be used to diagnose gout and how?

A

Dual energy computed tomography (DECT)

Able to detect uric acid crystal deposits

Can measure MSU (monosodium urate crystals) volume

Changes in actual MSU following treatment

Needle biopsy to assess uric acid crystal deposits

27
Q

How can gout cause joint damage?

A

Gout causes the production of Tophaceous deposits which cause joint erosions

These and monosodium urate crystals surrounded by
granulomatous tissue reaction
It Produces pro-inflammatory cytokines (IL1, TNF, IL6)

Stimulate osteoclasts (RANKL)

28
Q

How is an acute attack of gout treated?

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

Corticosteroids
For those that can’t use NSAID or colchicine

IL1 biologicals
Rilonacept, canakinumab, anakinra
Reduces length of attack and reoccurrences
Used for patients who have severe and frequent flares

29
Q

Which life style changes should be made by those who have gout?

A

Low Purine diet change

Can eat- veg, cheese, eggs

Moderate- Fish, meat, chicken

Avoid- Tuna, yeast, peanuts, internal organs

30
Q

How is chronic gout treated?

A

The aim is to reduce the uric acid levels:

Drugs-
Allopurinol- blocks xanthine oxidase
- Reduces generation of uric acid

Probenecid- Increases uric acid excretion (uricosuric)
Fewer significant adverse effects than allopurinol

Rasburicase-
Catalyses conversion of uric acid to allantoin

31
Q

Name an alternative drug for Allopurinol? Name 1 main difference between the 2

A

Febuxostat, a nonpurine selective inhibitor of xanthine oxidase

This is metabolised mainly in the liver (used for those with renal insufficiency)

Allopurinol and its metabolites are excreted primarily by the kidney

32
Q

What is Pseudogout?

A

Calcium pyrophosphate deposition disease

Acute deposition of calcium pyrophosphate crystals in and around joints

Chondrocalcinosis- Calcium deposition in cartilage

33
Q

What is Chondrocalcinosis?

A

Calcium deposition in cartilage

34
Q

There are 2 presentation of Pseudo-gout describe them

A

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

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

Asymptomatic where only radiographic findings and no other symptoms

35
Q

What is the pathophysiology of pseudogout?

A

Calcium pyrophosphate deposition crystals in the joint space causes

phagocytosis of the crystals by monocyte-macrophages or neutrophils

these then release cytokines which cause inflammation

36
Q

Which joint is most affected in pseudogout?

A

Knee is most commonly affected joint but can affect any joint

37
Q

What can trigger an acute attack for Pseudogout?

A

Trauma

Rapid reduction of serum calcium concentration

38
Q

How is Pseudogout diagnosed?

A

Synovial fluid
Mild to moderate inflammation 10,000-50,000 WBCs/μL 90% neutrophils (PMNs)
Rhomboid shaped weakly birefringent crystals

Ultrasound-

  • Calcification within soft tissue
  • Calcification within the articular cartilage

Chondrocalcinosis of articular disc and atypical OA of hands
Often OA in same or neighbouring joints

39
Q

How is Pseudogout treated?

A

Intra-articular corticosteroids

NSAIDs

40
Q

List 5 differences between gout and pseudogout

A

In gout - males are significantly more affected than females
This is not the same for pseudogout

Age- For gout >30-40
for pseudogout- Elderly

Serum urate- Elevated in gout
Normal in pseudogout

Involvement of 1st metatarsal -
Common in gout
Rare in pseudogout

Radiographic findings
Gout- Erosions with overhanging adges
Pseudogout- chondrocalcinosis

Cystals-
Gout- Needles shaped, negative birefringent

Pseudogout- Rhomboid-shaped - weakly positive birefringent

41
Q

In which disease will you find Cholesterol crystals?

A

rheumatoid arthritis

42
Q

List 4 causes of Cholesterol crystals

A

Defective drainage of synovial fluid back into venous system

Increased permeability of synovial membrane to LDL and HDL

Intra-articular bleeding

Locomotor Y2 (8 decks)

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