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MSK > GOUT > Flashcards

GOUT Flashcards

1
Q

Features of crystal arthritis

A
  • Crystal Arthritis is the commonest cause of acute joint swelling
  • Gout most common in men
  • Pseudogout in women
  • Easy to diagnose and treat
  • Miserable for patients
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2
Q

Gout features

A
  • Caused by the deposition of monosodium urate crystals within joint
  • The immunological reaction initiated to try and remove them, leads to acute pain and swelling
  • Only ‘Curable’ form of inflammatory arthritis
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3
Q

Epidemiology of gout

A

UK General Practice Research Database – prevalence 1.4% (1999)
7.3% of men aged >75yrs
Overall male : female ratio 5:1

Hyperuricaemia much more common – affects 15% population
Gout prevalence increases with age

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4
Q

Pathogenesis of Gout

A

Under exretion urate + overproduction urate >
Hyperuricaemia >
Crystal formation & shedding >
Synovial cells > Inflammatory response

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5
Q

What causes under excretion urate in gout

A

Genetics
Drugs
CKD
Diuretics
Lead toxicity

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6
Q

What causes overproduction of urate in gout

A

Diet
Alcohol
Metabolic proliferation
Obesity
Psoriasis
Purine rich diet

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7
Q

Causes of Gout

A

Alcohol - mostly beer
Red meat, shellfish, offal
Soft drifts
Psoriasis
Haematological malignancy

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8
Q

Essential risk factors for Gout

A

Renal impairment
Beer
Diuretics
Aspirin
Family History
Fructose
Elderly
Men
Impaired renal function

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9
Q

Clinical features of Gout

A
  • Acute episodes
  • Onset often at night
  • Resolve spontaneously (quicker with treatment)
  • Usually recur in a predictable pattern of joint involvement
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10
Q

Typical joints that gout affects

A
  • 1st MTPJ 90%
  • Midfoot, ankle, knee, wrist, elbow hand
  • Periarticular involvement
  • Olecranon bursitis
  • Systemic features can occur
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11
Q

Differntial diagnosis for Gout

A

Septic Arthritis
Trauma
Pseudogout
Rheumatoid Arthritis
(Osteoarthritis!)

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12
Q

Investigations for Gout

A

FBC (expect raised WCC)
U+E
LFT if concern re alcohol
Serum Uric Acid (often normal during acute attack)
CRP
Xray if recurrent episodes or concern re sepsis
Joint aspiration
Joint X ray

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13
Q

4 clinical phases of gout

A

 asymptomatic hyperuricemia,
 acute/recurrent gout,
 intercritical gout,
 chronic tophaceous gout

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14
Q

Acute treatment of Gout

A

Explain the disease
Advice about lifestyle - alcohol diet weight loss fluid intake
NSAID (short course) unless:
Renal failure
Peptic Ulcer Disease
Some pts with asthma

Colchicine
500ug 2-3 times daily

Corticosteroids
Intra-articular
Oral - low dose (5-10mg short course)
Ice packs

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15
Q

Indication of chronic gout

A
  1. Recurrent attacks
  2. Evidence of tophi or chronic gouty arthritis
  3. Associated renal disease
  4. Normal serum Uric acid cannot be achieved by life-style
    modifications
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16
Q

Medications for chronic gout

A
  1. Allopurinol – Xanthine Oxidase Inhibitor
  2. Febuxostat – more potent Xanthine Oxidase Inhibitor
  3. Benzbromarone / Probencid – if allergic / intollerant
17
Q

Complications of Gout

A

Disability and misery
Tophi
Renal disease:
Calculi 10 -15%
Chronic urate nephropathy
Acute urate nephropathy (cytotoxics

18
Q

Gout pathophysiology

A

Uric acid has limited solubility in the blood.

When there is too much uric acid in the blood, it can become a urate ion and bind sodium, leading to the formation of monosodium urate crystals

which deposit in areas with slow blood flow, including joints and kidney tubules.

19
Q

Signs of Gout

A

Joint inflammation
Gouty tophi

20
Q

Symptoms of Gout

A
  • Red, tender, hot, and swollen joint.
  • Joint stiffness
  • Rapid onset severe joint pain
21
Q

Complications of Gout

A

Urate nephrolithiasis: there is an association between gout and urate renal stones due to hyperuricaemia

22
Q

What is pseudogout?

A

Pseudogout is a form of inflammatory arthritis caused by deposition of calcium pyrophosphate crystals in the synovium.

23
Q

Pseudogout epidemiology

A

Mostly women
Most patients affected by acute pseudogout are over the age of 65

24
Q

RF for pseudogout

A
  • Increasing age: the greatest known risk factor for pseudogout
  • Previous joint trauma
  • Hyperparathyroidism
  • Haemochromatosis
  • Acromegaly
  • Wilson’s disease
  • Hypomagnesaemia
  • Hypophosphataemia
25
Q

Pathophysiology of pseudogout

A

The deposition of calcium pyrophosphate crystals is thought to trigger synovitis, with the knee, shoulder, and wrist being most commonly affected.

26
Q

Acute pseudogout

A

Acute - mainly affects larger joints in the elderly and is usually spontaneous but can be provoked by illness, surgery or trauma

27
Q

Chronic Pseudogout

A

Chronic - inflammatory RA-like symmetrical polyarthritis and synovitis

28
Q

Signs of Pseudogout

A

Very similar to gout and usually indistinguishable until joint aspiration is performed.

  • Joint inflammation: pain, erythema and swelling
  • Signs can be monoarticular (1 joint) or polyarticular (several joints)
29
Q

Symptoms of Pseudogout

A
  • Rapid onset severe joint pain: knee, shoulder and wrist are most commonly affected
  • Joint stiffness
30
Q

Primary investigations for pseudogout

A
  • Joint aspiration:weakly-positively birefringent rhomboid-shaped crystals under polarised microscopy confirm the diagnosis. If any bacterial growth, then patient is likely to have septic arthritis
  • Joint X-ray:chondrocalcinosis (calcification of articular cartilage) is seen in 40% of casesand is highly suggestive of pseudogout but is not diagnostic; theabsenceof chondrocalcinosis doesnotexclude pseudogout
    In the knee, this is seen as linear calcifications of the articular cartilage and meniscus
31
Q

Investigating the underlying cause for pseudogout

A

Usually only done in young patients:

  • Serum bone profile and PTH: investigate for hyperparathyroidism and hypophosphataemia
  • Iron studies: investigate for haemochromatosis
  • Serum magnesium: investigate for hypomagnesaemia
32
Q

DD for pseudogout

A
  • Gout
  • Septic arthritis
  • Rheumatoid arthritis
  • Osteoarthritis
33
Q

Acute management for Pseudogout

A
  • Anti-inflammatory:NSAIDs or colchicine, particularly in polyarticular disease
  • Corticosteroid:intra-articularsteroids can be used in monoarticular disease orsystemicsteroids in polyarticular disease
  • Cool packs and rest
  • Aspiration of the joints - relieves pain
34
Q

Chronic management for Pseudogout

A
  • DMARDs: e.g. methotrexate and hydroxychloroquine may be considered in chronic pseudogout
  • Joint replacement: only indicated in chronic, recurrent cases with severe joint degeneration
35
Q

Prognosis Pseudogout

A

Resolution usually happens within a few days of treatment but some can become chronic

36
Q

Gout X ray

A

JOint space maintained
Lytic lesions in bone
Punched out erosions
Erosions can have sclerotic borders

MSK (20 decks)

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