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Year 3 - Muscoloskeletal > Crystal arthropathy (gout, pseudogout) > Flashcards

Crystal arthropathy (gout, pseudogout) Flashcards

1
Q

Define gout.

A

Disorder of uric acid metabolism causing recurrent bouts of acute arthritis caused by deposition of monosodium urate crystals in joints, and also soft tissues and kidneys.

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2
Q

What is the aetiology of gout?

A

Metabolic disturbance is hyperuricaemia which may be caused by:

  • Increased urate intake or production - increased dietary intake, increased nucelic acid (purine) turnover (e.g. lymphoma, leukaemia, polycythaemia vera, psoriasis) or rarely caused by increased synthesis (e.g. Lesch-Nyhan syndrome)
  • Decreased renal excretion - idiopathic, drugs (e.g. “CANT LEAP”), renal dysfunction
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3
Q

Which drugs can cause decreased renal excretion of uric acid?

A

CANT LEAP

  • ciclosporin
  • alcohol
  • nicotinic acid
  • thiazides
  • loop diuretics
  • ethambutol
  • aspirin
  • pyrizinamide
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4
Q

How common is gout?

A
  • Prevalence 0.2%
  • M:F 10:1 ratio
  • Rare in pre-puberty and in pre-menopausal womrn
  • More common in higher social classes
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5
Q

What is the typical presentation of and acute attack of gout?

A

Acute attack -

  • May be precipitated by trauma, infection, alcohol, starvation, introduction or withdrawal pf hypouricaemic agents.
  • Suddent excruciating monoarticular pain, usually of metatarsophalangeal joint of the great toe.
  • Symptoms peak at 24 hours and resolve in 7-10days.
  • Occassionally acute attacks present with cellulitis, polyarticular or periacrticular involvement.
  • Attacks are often recurrent, but the patient is symptom free between attacks.
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6
Q

What are the three types of presentations of gout?

A
  • Acute attack
  • Intercritical gout
  • Chronic tophaceous gout
  • Urate urolithiasis (renal calculi)
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7
Q

What is the typical presentation of intercritical gout?

A

Asymptomatic period between acute attacks

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8
Q

What is the typical presentation of chronic tophaceous gout?

A
  • Follows repeated acute attacks
  • Persistent low-grade fever
  • Polyarticular pain with painful tophi (urate deposits)
  • Best seen on tendons and the pinna of the ear
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9
Q

What are the signs of gout on examination?

A
  • rapid-onset severe pain
  • joint stiffness
  • foot joint distribution
  • few affected joints
  • swelling and joint effusion
  • tenderness
  • tophi

Common

  • erythema and warmth
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10
Q

What investigations would you do for gout?

A
  • Synovial fluid aspirate - diagnosis depends on the presence of monosodium urate crystals which are needle-shaped and negatively birefingent under polarised light. Microscopy and culture (to exclude septic arthritis)

Bloods:

  • FBC - raised WCC
  • U&E
  • Urate - raised (but normal in acute gout). Should be obtained 2 weeks after acute attack resolves. >416 micromol/L (7 mg/dL) in men; >360 micromol/L (6 mg/dL) in women.
  • ESR - raised

Imaging:

  • AXR/KUB -uric acid renal stones are often radiolucent (i.e. not visible)
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11
Q

What lifestyle measures can you take to reduce gout?

A

Reduce meat and alcohol intake

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12
Q

How do you manage gout? (not required)

A

Attack - NSAID/colchicine + intra-articular corticosteroids + intramuscular ACTH if difficult to control

Surgery - if large or ulcerating tophus

Prophylaxis - allopurinol (xanthine oxidase inhibitor) or long term colchicine (risk of neuromyopathy), probenecid or sulfinpyrazon (uricosurics). Encourage high fluid intake to lower risk of renal calculi.

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13
Q

Define pseudogout.

A

Arthritis associated with deposition of calcium pyrophosphate dihydrate (CPPD) crystals in joint cartilage.

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14
Q

List some risk factors for gout.

A
  • older age
  • male sex
  • menopausal status
  • consumption of meat, seafood, alcohol
  • use of diuretics
  • use of ciclosporin (cyclosporine) or tacrolimus
  • use of pyrazinamide
  • use of aspirin
  • genetic susceptibility
  • high cell turnover state

weak:

  • adiposity and insulin resistance
  • hypertension
  • renal insufficiency
  • diabetes mellitus
  • hyperlipidaemia
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15
Q

What is the aetiology of pseudogout?

A
  • CPPD crystal formation is initiated in cartilage located near the surface of chondrocytes.
  • The disorder is associated with excessive cartilage pyrophosphate production leading to local calcium pyrophosphate supersaturation and CPPD crystal formation/deposition.
  • Shedding of crystals into the joint cavity precipitates acute arthritis.
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16
Q

What conditions/situations predispose to pseudogout?

A
  • Most causes of joint damage predispose to pseudogout (e.g. osteoarthritis, trauma).
  • More rarely, conditions such as haemochromatosis, hyperparathyroidism, hypomagnesaemia, hypophosphatasia can predispose to pseudogout.
  • Familial cases and associations with metabolic diseases have been described.
  • Provoking factors: Intercurrent illness, surgery, local trauma.
17
Q

How common is pseudogout/calcium pyrophosphate deposition?

A
  • Male:female ratio is 2:1
  • More common in elderly (>60yrs) but can occur in younger people with associated metabolic conditions
18
Q

What are the two presentation of pseudogout?

A
  1. Acute arthritis
  2. Chronic arthropathy

Uncommon presentations - tendonitis (e.g. achilles), tensynovitis (tendon of hand), bursitis (e.g. olecranon bursitis)

19
Q

Descirbe the presentations of acute and chronic pseudogout.

A

Acute arthritis - painful swollen joint (e.g. knee, ankle, shoulder, elbow, wrist)

Chronic arthropathy - pain, stiffness, functional impairment

20
Q

What are the signs of pseudogout on examination?

A

Acute arthritis -

  • red,
  • hot,
  • tender,
  • restricted movement range,
  • fever

Chronic arthropathy (similar to osteoarthritis) -

  • bony swelling,
  • crepitus,
  • deformity e.g. varus in knees,
  • restriction of movement
21
Q

What investgations would you do for pseudogout?

A

Bloods:

  • FBC - high WCC in acute attack
  • ESR - raised
  • Blood culture - excludes infective arthritis

Joint aspiration

  • Microscopy - rhomboid brick shaped crystals with peak positive birefringence under polarised light.
  • Culture or gram staining - to exclude infective arthritis

Imaging:

  • Xray of joint - chondrocalcinosis (linear calcification of cartilage) or signs of osteoarthritis.
22
Q

What are the signs of osteoarthritis on X ray ?

A
  • loss of joint space
  • osteophytes
  • subchondral cysts
  • sclerosis
23
Q

What are the signs of pseudogout on X ray?

A

Chondrocalcinosis (linear calcification)

24
Q

How do you manage pesudogout (not required) ?

A

Acute - aspiration + intra-articular steroids + NSAIDs/colchicine

Chronic - similar to osteoarthriris (e.g. lose weight, walking aids, physio, analgesia). Oral daily colchicine if >3 attacks/year.

Surgery if severe

25
Q

What is the difference between gout and pseudogout?

A

Year 3 - Muscoloskeletal (18 decks)

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