Gout Flashcards
t/f apatite can be seen in polarized light microscopy
false
musculoskeletal manifestations of crystal induced arthritis
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what is gout
- affects middle aged to elderly men and postmenopausal women
- increased body pool of urate with hyperuricemia
classic clinical features of msu crystals
- episodic acute arthritis
- chronic arthritis
- connective tissue tophi
- risk of kidney deposition or uric acid nephrolithiasis
risk factors for gout
- male
- diuretics
- high purine diet
- age / menopause
- hpn / hyperlipid / hypertag
stages of gout
- asymptomatic hyperuricemia
- acute gout with intercritical periods
- advanced gout
acute intermittent gout
- early: acute arthritis
- podagra
- one -> heberden’s / bouchard’s nodes -> polyarticular
- mimics bacterial cellulitis
- subside in 3-10 days
advanced or chronic tophaceous gout
- chronic nonsymmetric synovitis
- most characteristic lesion: sc tophus
diagnosis of gout
needle aspiration
- needle shaped msu crystals
- brightly birefringent with negative elongation with polarized light
synovial fluid analysis:
- 2,000 - 60,000 /ul WBC
- cloudy, chalky, pasty
- serum uric acid: normal or low at attack
- 24 hr collection of uric acid
imaging that shows advanced disease of gout
- cystic changes
- well defined erosions with sclerotic margins
- soft tissue masses
- double contour sign
acute treatment of gout
stop the attack
- nsaids
- colchicine 0.5 mg 3x a day
- corticosteroid
- anakinra
chronic treatment of gout
prevent the attack
- correct hyperuricemia (<300-360 umol/l or 5-6 mg/dl)
- begin when serum uric acid is >535 umol/l or >9 mg/dl
hypouricemic therapy
- probenacid
- benzbromarone
- allopurinol !!
- febuxostat
- pegloticase
__ is administered prior to urate lowering therapy as an anti inflammatory prophylaxis
colchicine
pathophysio of cppd
- ankh mutations
- elevated cppd and crystal deposition
- macrophages eat it = inflammatory cascade
- <50 yo = metabolic disorder
clinical features of cppd
- knee most affected
- polyarticular
- unusual joint distribution
- precipitated by trauma
- low serum calciym
imaging of cppd
chondrocalcinosis
definitive diagnosis of cppd
- rhomboid or rodlike crystals in synovial fluid
- neutrophil predominant
- weak birefringent or nonbirefringent
treatment of cppd
- nsaids
- glucocorticoids
- colchicine
- severe: systemic glucocorticoids, anakinra
- hydroxychloroquine or methotrexate
- rest and joint aspiration
- joint replacement
what is capd
- accumulation of basic calcium phosphates (carbonate apatite)
- areas: damaged tissue (dystrophic calcification)
- hypercalcemic or hyperparathyroid states
- chronic renal failure = hyperphosphatemia
clinical features of capd
- milwaukee shoulder
- minimum to severe pain and disability
- damage to joint capsule, tendons, bursae, articular surfaces
- sites: tendons and bursae of knees, shoulders, hips, fingers
what is milwaukee shoulder
- destructive chronic arthropathy of shoulder in elderly
- apatite in synovial fluid
- other sites: hips, knees, erosive osteoarthritis of fingers
imaging of capd
- xray: intra or periarticular calcification +/- erosion/ hypertrophy
- electron micro: 1-2 um shiny intra/extracellular nonbifringent globules or aggregates
- purple = wright, red = alizarin
treatment of capd
- aspirations of effutions + nsaids, colchicine, glucocorticoids
- anakinra + edta (shoulder)
- ivg, rituximab, ca channel blockers, bisphosphonates
what is primary oxalosis
- enhanced production of oxalic acid = hyperoxalemia and deposition of caox
- nephrocalcinosis, renal failure, death before 20
what is secondary oxalosis
- caox deposits in organs, bv, bones, and cartilage
- causes arthritis in chronic renal failure
- pts in long term peritoneal dialysis or hemodialysis + ascorbic acid supplements
clincial features of caox dd
- caox aggregates = acute synovitis
- persistent aggregates = synovial cell proliferation and enzyme release
- fingers, wrists, elbows, knees, ankles, feet
diagnosis of caox dd
- xray: chondrocalcinosis or soft tissue calcifications
- synovial fluid: variable shape and birefingence
- classing: bipyramidal and small polymorphic caox crystals
tx for caoxdd
- nsaids, colchicine, glucocorticoids, increased dialysis
- primary: liver transplant
most critical diagnosis
infection
normal and inflammatory and septic synovial fluid
normal: clear or pale straw, viscous, (+) string sign = hyaluronate
inflammatory: slightly cloudy, loss of viscosity, (-) string sign
septic: pus
wbc counts
> 2000/uL = inflammatory / septic
>50,000 uL = septic
