Crystalline Arthropathies Flashcards
How common is gout?
Common, about 2% of the population is affected
Gout is one of a group of diseases characterized by ___ throughout the body
crystalline deposition
What must be elevated in the blood to predispose gout?
Uric acid
normal byproduct of purine metabolism
What type of patient is most likely to present with gout?
Why is this so?
Older (40-50s) males
Males produce more uric acid than females
What are the crystals composed of in gout?
Uric acid
sodium monourate
What are the etiologies of gout?
- 85% idiopathic impairment of renal uric acid excretion
- Genetic (purine metabolism)
- Stress
- Alcoholism
- Diabetes (long term)
How might alcoholism lead to gout?
- Beer and red wine increase purines, thus increasing uric acid
- Can lead to renal disease, gout would be secondary to kidney issues
What is the pathogenesis of gout?
- Overproduction of purine metabolic byproducts (uric acid)
- Inability to dispose of/break down metabolic byproducts
A patient comes in for a routine urinalysis and has hyperuricemia, but does not report any related symptoms.
Do they have gout?
No gout
A patient reports that their great toe is big, red, and swollen. They noticed this, along with other acute arthritis symptoms, shortly after a bout of alcohol consumption. Upon urinalysis, the patient has hyperuricemia.
What is the diagnosis?
Gout
Primary gout is the case for ___ of patients with gout
What makes gout primary?
1/3
Etiology is metabolic overproduction of uric acid
Secondary gout is the case for ___ of patients with gout
What makes gout secondary?
2/3
Underlying pathological etiology is present
What are some underlying pathologies that can lead to secondary gout?
- Multiple myeloma (protein in blood destroys kidneys)
- Alcoholism
- Diabetes (destroys kidneys)
- Kidney disease
In the pathogenesis of gout, uric acid crystals deposit in the soft tissue of an extremity joint.
What sort of pain will result from this?
Uric acid crystals are not irritating; found in asymptomatic joints
gout
Urate crystals are phagocytized by ___
PMNs and macrophages
gout
PMNs and macrophages try to phagocytize urate crystals, which induces a release of leukotrienes, cytokines, and chemotactins that elicit an intense ___
inflammatory reaction
gout
PMNs and macrophages try to phagocytize urate crystals, which induces a release of ___, ___, and ___ that elicit an intense inflammatory reaction
leukotrienes, cytokines, and chemotactins
How does chronic gout lead to joint destruction?
Lysosomes and other enzymes released
If untreated, gout will generally resolve in about ___, but can recur ___ later
gout will generally resolve in about 1 week, but can recur months to years later
What is the differential diagnosis for what grossly appears to be gout?
Septic arthritis
big, red, swollen joint; occurs quickly
What is the differential diagnosis for septic arthritis presenting as a single swollen red joint in the lower extremity?
Gout
What test differentiates gout from septic arthritis?
Joint aspiration:
- Septic arthritis reveals purulent exudate
- Gout appears clear with crystals
90% of patients with gout have ___
acute arthritis
How often is gout chronic?
What makes gout chronic?
10-15% chronic
Demonstrates pannus production and destruction
pannus production and destruction also presents with rheumatoid arthritis
How many joints are usually affected by gout?
One or two
often intially podagra (great toe)
Besides the great toe, what are some common locations for gout?
Peripheral joints:
- Instep
- Heel
- Ankle
- Knee
- Wrist
(not spine)
Which clinical manifestation is indicative of chronic gout?
Tophi (chalky deposit)
What are tophi?
A chalky deposit; monosodium urate (crystal) deposit in soft tissues
found in chronic gout
develop over 10-20 years time
What are the cardinal signs of gout?
Rubor, calor, dolor, tumor
(all of them)
What is the pattern of pain with gout?
Begins at night and builds rapidly over 24 hours
What are some clinical manifestations of gout?
- Tophi
- Cardinal signs
- Pain at night, gets worse over a day
- Hyperuricemia
- Renal impairment in chronic cases
What are the 4 stages of gout?
- Asymptomatic hyperuricemia
- Acute gouty arthritis
- Polyarticular gouty arthritis
- Chronic tophaceous gout
How does chronic tophaceous gout characteristically appear?
Tophi presenting as lumpy bumpy joints
A patient presents with a red, swollen bump at their first metatarsophalangeal joint.
What is your differential diagnosis?
- Septic arthritis (infection)
- Gout
- Rheumatoid arthritis
infection can also be cellulitis, osteomyelitis, etc.
Does gout have to be in joints?
No, it is a soft tissue disease
What are three radiographic characteristics of gout?
- Marginal erosions
- Periarticular erosions
- Intraosseous erosions
subchondral white line maintained
gout
What is a corticated erosion?
Marginal erosion: has an overhanging margin due to a longer remission period that allowed for some regrowth/repair
gout
What is a periarticular erosion?
Deposits from periarticular soft tissues erode the bone
gout
What is an intraosseous erosion?
Deposits within the bone (intraosseous tophus with or without calcification)
A patient’s radiograph of their great toe reveals corticated marginal erosions, periarticular erosions, and intraosseous erosions around the metatarsophalangeal joint.
What is your differential diagnosis?
Gout
erosion followed by remission
rheumatoid arthritis and psoriatic arthritis have non-corticated margins
A patient’s radiograph of their swollen elbow displays what looks like gouty crystals in the olecranon bursa.
What is your differential diagnosis?
- Gout
- Olecranon septic bursitis
Gout should first be treated with a low purine, high water intake diet and a referral to a rheumatologist.
What are some drug therapies they might be prescribed?
- NSAIDs (early, short-term)
- Corticosteroids (acute, short-term)
- Colchicine
- Allopurinol
- Uloric
avoid corticosteroids for recurring gout
A patient comes in and reports that they take colchicine.
Why might they be taking this medication?
Used for recurrent attacks of gout or acute CPPD
A patient comes in and reports that they take allopurinol.
Why might they be taking this medication?
Inhibits xanthine oxidase, treats gout
Joint destruction due to gout is radiographically visible after ___.
7 years
A patient reports that they had a big, red, swollen heel that went away on its own in about a week without treatment.
Was this more likely a case of gout or septic arthritis?
Gout
infection takes longer to heal
What is the defining pattern of gout recurrence?
Exacerbation and remission
exacerbation will get longer and remission shorter
Both gout and septic arthritis will have increased white blood cells.
What additional information about white blood cells differentiates the two?
Infectious disease (septic arthritis) has increased white blood cells with a left shit
gout has no wbc shift
uric acid will also be normal in septic arthritis
What is the full name of CPPD?
Calcium Pyrophosphate Dihydrate Crystal Deposition Disease
CPPD deposition disease is also called ___
pseudogout
CPPD looks like ___ because it is a big, red, swollen joint with exacerbation and remission
gout and septic arthritis
CPPD entails ___ crystals in ___ leading to inflammation
calcium pyrophosphate crystals in hyaline and fibro-cartilage
Onset of CPPD occurs at ___ years of age and peaks at age ___
onset at 30
peak at 60
CPPD is experienced by ___ of those over age 85
half
What are four other joint pathologies that CPPD may simulate?
- Gout
- Rheumatoid arthritis
- Degenerative joint disease
- Neuropathic arthropathy
Generally, gout precipitates in ___,
CPPD precipitates in ___
soft tissue
cartilage
What is a key difference between CPPD and rheumatoid arthritis?
Rheumatoid arthritis can be bilateral and symmetrical, CPPD cannot
What is a key difference between CPPD and DJD?
DJD is associated with deep, dull, achy pain
CPPD is usually asymptomatic (at least early on)
What is a key difference between CPPD and neuropathic arthropathy?
NA has a slower destruction than CPPD
What are some etiologies of CPPD deposition disease?
- Idiopathic
- Hereditary (rare)
- Trauma
- Metabolic disorders
Phagocytosis of CPPD crystals by ___ leads to release of inflammatory mediators
synovial fluid and neutrophils
Phagocytosis of CPPD crystal by synovial fluid and neutrophils leads to release of ___
inflammatory mediators
In the pathogenesis of CPPD deposition disease, attacks are initially ___, but become ___
monoarticular, but become polyarticular
Acute CPPD deposition disease attacks may be self-limiting lasting a day to several days.
What is this similar to?
Gout
An acute CPPD deposition disease attack may be self-limiting.
How might a severe attack resolve?
Involving peripheral and axial joints, resolves slowly over weeks
CPPD crystals may accumulate in which tissues?
- Synovial membranes (pseudogout)
- Articular cartilage (chondrocalcinosis) (hyaline and fibrocartilage)
- Tendons and ligaments
What are some clinical manifestations of CPPD deposition?
- Chronic progressive joint pain
- Reduced ROM with stiffness
- Crepitus
Joint destruction from CPPD will be seen radiographically within ___ years
For gout, destruction will be seen after about ___ years
CPPD = 2 years
Gout = 7 years
What are some radiographic characteristics of CPPD deposition disease?
- Cartilage, synovium, tendons, and/or ligament involvement
- Crystal deposition in peripheral joints (knees, wrists, hands)
How does chondrocalcinosis appear radiographically?
Cartilage (hyaline or fibro-) is visible
CPPD
A patient’s radiographs show bright cartilage in the knee.
You think it’s chondrocalcinosis, but you should rule out ___.
joint degeneration
A patient’s radiographs show bright cartilage in the knee.
What information would help you narrow your differential diagnosis?
- History: symptoms
- Joint aspiration
labs aren’t very helpful
DDx: chondrocalcinosis/CPPD, joint degeneration
A patient’s radiographs present calcification in the meniscus of the knee (fibrocartilage), the hyaline cartilage, and the synovial membrane.
What is the likely diagnosis?
CPPD deposition disease
pyrophosphate arthropathy
What are five treatments that CPPD responds to?
- Rest
- Joint protection
- NSAIDs
- Colchicine (in acute attacks)
- Corticosteroids (only during exacerbation)
Would CPPD respond to DMARDs?
No
What is the long term for HADD?
(Calcium) Hydroxyapatite Deposition Disease
What is another condition that may be in the differential diagnosis of HADD?
CPPD
CPPD occurs in cartilage.
Which tissues will HADD occur in?
Bursa, ligaments, and tendons
HADD a BLT
Calcium hydroxyapatite deposition disease is also known as ___
calcific tendinosis (most common deposit), calcific bursitis
HADD involves ___ deposition in leukocytes and mononuclear cells in joints and synovial fluid
hydroxyapatite
HADD involves hydroxyapatite deposition in ___ and ___ in joints and synovial fluid
leukocytes and mononuclear cells
Where in the joint might calcification occur if a patient has HADD?
Within tendon, bursa, capsule, or ligament
What are the typical etiologies of HADD?
Post-traumatic / degenerative nature
Where in the body might calcification occur if a patient has HADD?
- Most commonly shoulder (rotator cuff)
- Hip
- Cervical spine
How might HADD in the shoulder present?
Presents as supraspinatus tendinosis
rotator cuff symptoms
How might HADD in the cervical spine present?
Presents in longus coli tendon for around 2 weeks
presents like torticollis
cannot treat, refer for pain management
HADD may be asymptomatic at first
What symptoms follow?
Painful attacks lasting days to months
HADD has been shown to respond well to ___
ultrasound (or shock wave) to break up calcium
What age group is most commonly affected by HADD?
Patients over 40-years-old
If a patient’s radiographs present with calcifications in the bursa and capsule of their shoulder, what is the likely diagnosis?
HADD (calcium hydroxyapatite deposition disease)
Is gout inflammatory?
Yes
Is HADD inflammatory?
Yes
Is CPPD inflammatory?
Yes
