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ICM Exam 2: Infectious Disease (& CIA) > Crystal induced arthropathies > Flashcards

Crystal induced arthropathies Flashcards

1
Q

Uric acid solubility limit

A

6.8 mg/dL

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2
Q

Medication that predisposes to gout

A

Thiazides

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3
Q

Congenital syndrome that predisposes to gout

A

Lesch Nyhan (HGPRT deficiency)

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4
Q

Uric acid excretion

A

80% renal

20% GI

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5
Q

Key player in acute gout flare

A

IL1

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6
Q

Causes of Hyperuricemia (seondary to…)

A

10% secondary to overproduction

90% to underexcretion

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7
Q

Rreactions using HGPRT

A

Guanine to Guanylic acid

HX to Inosinic acid

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8
Q

Uric Acid Secondary overproduction

(excluding alcohol and purine foods)

A
  • Myelo/Lympho proliferative
  • Malignancy
  • Hemolytic diseases
  • Psoriasis
  • Obesity
  • Chemo
  • Down Syndrome
  • Glycogen storage disease
  • Pancreatic extract, Nicotinic acid
  • B12 deficiency
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9
Q

Why does alcohol increase risk for hyperuricemia

A

needs ATP = higher puine turnover

Lactate elevation and decreased renal excretion via URAT-1

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10
Q

Majority of renal excretion uses..

A

complex series of transport proteins

URAT

OAT

NPT

ABCG

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11
Q

Kidney excretes of about ___% of filtered urate load

A

10%

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12
Q

__% of urate is re-secreted

A

50%

80% of the resulting load is reabsorbed in the ascending limb

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13
Q

Primary causes of underexcretion

A

Deficiency of Urate transporter (exporter)

Medulary cystic kidney disease (kids)

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14
Q

Secondary renal underexcretion causes

A
  • Kidney disease
  • Lactic acidosis/ DKA
  • Dehydration
  • HypoPTH and Hypothyroidism
  • Sarcoid
  • Preeclampsia
  • SODIUM WASTING or VOLUME DEPLETION
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15
Q

Drugs that promote hyperuricemia

A
  1. Thiazides, loop diuretics
  2. Orgaic acids (salicyclate, NA, Pyrizinamide)
  3. Cylcosporine
  4. ethambutol
  5. levadopa
  6. CSF
  7. Lead Tox.
  8. Laxative abuse
  9. Severe salt restriction
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16
Q

What hppens when gout spreads beyond joint

A

Tenosynovitis mimicking cellulitis

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17
Q

Diagnosis of gout involves

A

Joint aspiration!

HU + joint effusion NOT enough for definitive

Can mimic septic arthritis

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18
Q

____ are good at finding gouty erosions

A

MRI/CT

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19
Q

Sign for gout in ultrasound

A

Double contour sign (urate icing) = irregular band on surface of articular cartilage

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20
Q

Most important indication for arthrocentesis

A

check for septic arthritis

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21
Q

WBC above ____ assume septic and give AB

A

50k

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22
Q

difference between blood from traumatic aspiration and hemarthrosis?

A

Red streaks in otherwise yellow fluid = TA

Homogenously bloody and NO clot = HA

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23
Q

Specificity for MSU visualization on polarized light

A

Near 100%

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24
Q

Three stages of gout

A

Acute

Intercritical

Chronic Tophaceous

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25
Other complications for gout
Bursitis Tenosynovitis Tendinitis
26
Most untreated gout patient will have...
recurrence within 2 years
27
Bony erosions and deformaties occur during
Chronic recurrent gout
28
Defining characteristic of tophaceous gout
Solid urate deposits in tissues
29
Tx goal to prevent disease progression
Lower urate to less than 6mg/dL = deplete urate from serum (also to correct the underlying cause)
30
Tx combo for acute gout
NSAID + Colchicine + GC's + IL-1b antagonist
31
What dont you do during a flare?
Dont try to lower urate levels! You'll make the attack worse because crystals will get mobilized.
32
Medication to increase excretion
Probenecid
33
What to do after first attack?
Avoid dehydration Modify meds (losartan) Reduce alcohol intake Lose weight
34
Medications to reduce production
allopurinol febuxostat PEG-uricase
35
Prophylaxis against attacks with...
Colchicine and NSAIDs
36
Uricosuric agents: Function Examples
increases secretion into urine **Probenecid** - Potent, limited use in CKD and nephrolithiasis **Benzbromarone** = less potent but can be used in renal disease **Losartan** or **Fenofibrate** = for mild disease with HTN or hyperlipidemia
37
Allopurinol MOA May be effective in \_\_\_\_\_\_ Sides?
XO inhibitor underexcretors Toxic epidermal necrolysis, vasculitis, BM supression
38
Interaction with allopurinol
thiazide use or allergy to Pen
39
Febuxostat MOA
blocks XO no dose adjustment for renal patients
40
Uricase enzymes function
Catalyzes the oxidation of uric acid o 5OH isourate --\> converted to allantoin (excreted) \*humans have a NONFUNTIONAL gene for uricase (because uric acid is a powerful antioxidant)
41
Uricase enzymes examples:
**Pegloticase** = recombinant porcine uricase, modified by covalent linkage to PEG \*\*reserved for refractory tophaceous gout \*\*prophylaxis with colchicine NSAIDs or CS for first 6 months **Rasburicase** = nonPegylated recombinant uricase = for BRIEF cuorses and prevention of neuropathy
42
CPPD etiology
Excessive cartilage pyrophosphate production leads to CPPD crystals deposit in * Joint hylaine cartilage * fibrocartilage * ligaments
43
Acute release of CPPD crystals into joint space causes _______________ \>\> \_\_\_\_\_\_\_\_\_\_\_\_\_
phagocytosis by MQ Release of chemotactic substances and activation of inflammasome
44
CPPD can cause \_\_\_\_\_
chondrocalcinosis
45
CPPD doesnt always have radiographic evidence, so ___ is helpful
US
46
Extracellular ........ yields PP
EC ATP scavenging by **nucleoside triphosphate pyrophosphate hydrolase** yields PP
47
CPPD prevalenece
equal in gender, increases with age
48
CPPD a complication of \_\_\_\_
primary OA
49
Other diseases that predispose to CPPD
Familial chondrocalcinosis Gitelman syndrome
50
Explain Gitelman
Mimics thiazide presents with Hypokalemia, Met. Acidosis, hypoMagnesemia, Hypocalciuria, and normal BP
51
What systemic metabolic disease associates with CPPD
Primary Hyperparathyroidism
52
pseudogout typically affects
larger joints (knee)
53
pseudogout flares following...
parathyroidectomy (low calcium = partial dissolution of crystals = release into joint fluid)
54
Pseudogout aka
acute CPP crystal arthritis
55
Chronic CPP inflammatory arthritis aka
pseudo-RA
56
In pseudo-RA, Radiographic changes are...
more typical of OA than RA
57
CPPD crystals are ___ refringent and ____ whe parallel to the light
Positive Blue
58
CPPD aspirate tends to be
inflammatory (90% PMN with 15-30k cells)
59
X ray findings of CPPD
* Beak like projections at 2nd/3rd Metacarpal heads * Subchondral cysts * chondrocalcinosis
60
61
CPPD deposits present with...
* **Hyperechoic** bands parallel to cartilage surface of knee * **Punctate** pattern with hyperechoic spots * Homogenous hyperechoic nodular or oval deposits in bursae
62
Treatment of pseudogout involving more than one joint
intraarticular glucocorticoids
63
Indications for pseudogout prophylaxis
if more than 3 per year = low dose **colchicine** Refractory or chronic = **MTX** or **hydroxychloroquine** Reurrent acute or severe = **IL-1b inhibitor**
64
Other deposition closely tied to OA
Hydroxyaapatite (Basic Ca Phosphate) crystals
65
Elderly women get this with Hydroxyapatite deposition disease
Milwaukee shoulder extremely destructive, hemorrhagic ffusions, synovial fluid has BCP crystals
66
BCP Tx
* NSAID or COX2 inhibitors * Intra-articular injections * Local irrigation * ULTRASOUND to degrade crystals \*Agents to lower phosphate levels = resorption of deposits in RF patients
67
_Calcium Oxalate Deposition Disease:_ Primary and secondary disease = Ascorbate metabolism and clearance =
Primary = enyme defect, overproduction of oxalic acid = nephrocalcinosis Secondary = MORE COMMON, metabolic abnormality complicating end-stage renal disease \*Ascorbate is metabolozed to oxalate... inadequately cleared in uremia and by dialysis patients
68
CaOx induced synovial effusions are usually \_\_\_\_
Noninflammatory
69
Shape of CaOx
Bipyramidal Stain with ALIZARIN RED
70
CaOx therapy
NSAIDs Colchicine IA GC's LIVER TRANSPLANT in primary oxalosis

ICM Exam 2: Infectious Disease (& CIA) (10 decks)

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