Gout

Question 1

t/f apatite can be seen in polarized light microscopy

Answer 1

false

Question 2

musculoskeletal manifestations of crystal induced arthritis

Answer 2

read

Question 3

what is gout

Answer 3

• affects middle aged to elderly men and postmenopausal women
• increased body pool of urate with hyperuricemia

Question 4

classic clinical features of msu crystals

Answer 4

• episodic acute arthritis
• chronic arthritis
• connective tissue tophi
• risk of kidney deposition or uric acid nephrolithiasis

Question 5

risk factors for gout

Answer 5

• male
• diuretics
• high purine diet
• age / menopause
• hpn / hyperlipid / hypertag

Question 6

stages of gout

Answer 6

• asymptomatic hyperuricemia
• acute gout with intercritical periods
• advanced gout

Question 7

acute intermittent gout

Answer 7

• early: acute arthritis
• podagra
• one -> heberden’s / bouchard’s nodes -> polyarticular
• mimics bacterial cellulitis
• subside in 3-10 days

Question 8

advanced or chronic tophaceous gout

Answer 8

• chronic nonsymmetric synovitis

- most characteristic lesion: sc tophus

Question 9

diagnosis of gout

Answer 9

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

Question 10

imaging that shows advanced disease of gout

Answer 10

• cystic changes
• well defined erosions with sclerotic margins
• soft tissue masses
• double contour sign

Question 11

acute treatment of gout

Answer 11

stop the attack

• nsaids
• colchicine 0.5 mg 3x a day
• corticosteroid
• anakinra

Question 12

chronic treatment of gout

Answer 12

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

Question 13

hypouricemic therapy

Answer 13

• probenacid
• benzbromarone
• allopurinol !!
• febuxostat
• pegloticase

Question 14

__ is administered prior to urate lowering therapy as an anti inflammatory prophylaxis

Answer 14

colchicine

Question 15

pathophysio of cppd

Answer 15

• ankh mutations
• elevated cppd and crystal deposition
• macrophages eat it = inflammatory cascade
• <50 yo = metabolic disorder

Question 16

clinical features of cppd

Answer 16

• knee most affected
• polyarticular
• unusual joint distribution
• precipitated by trauma
• low serum calciym

Question 17

imaging of cppd

Answer 17

chondrocalcinosis

Question 18

definitive diagnosis of cppd

Answer 18

• rhomboid or rodlike crystals in synovial fluid
• neutrophil predominant
• weak birefringent or nonbirefringent

Question 19

treatment of cppd

Answer 19

• nsaids
• glucocorticoids
• colchicine
• severe: systemic glucocorticoids, anakinra
• hydroxychloroquine or methotrexate
• rest and joint aspiration
• joint replacement

Question 20

what is capd

Answer 20

• accumulation of basic calcium phosphates (carbonate apatite)
• areas: damaged tissue (dystrophic calcification)
• hypercalcemic or hyperparathyroid states
• chronic renal failure = hyperphosphatemia

Question 21

clinical features of capd

Answer 21

• 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

Question 22

what is milwaukee shoulder

Answer 22

• destructive chronic arthropathy of shoulder in elderly
• apatite in synovial fluid
• other sites: hips, knees, erosive osteoarthritis of fingers

Question 23

imaging of capd

Answer 23

• xray: intra or periarticular calcification +/- erosion/ hypertrophy
• electron micro: 1-2 um shiny intra/extracellular nonbifringent globules or aggregates
• purple = wright, red = alizarin

Question 24

treatment of capd

Answer 24

• aspirations of effutions + nsaids, colchicine, glucocorticoids
• anakinra + edta (shoulder)
• ivg, rituximab, ca channel blockers, bisphosphonates

Question 25

what is primary oxalosis

Answer 25

• enhanced production of oxalic acid = hyperoxalemia and deposition of caox
• nephrocalcinosis, renal failure, death before 20

Question 26

what is secondary oxalosis

Answer 26

• 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

Question 27

clincial features of caox dd

Answer 27

• caox aggregates = acute synovitis
• persistent aggregates = synovial cell proliferation and enzyme release
• fingers, wrists, elbows, knees, ankles, feet

Question 28

diagnosis of caox dd

Answer 28

• xray: chondrocalcinosis or soft tissue calcifications
• synovial fluid: variable shape and birefingence
• classing: bipyramidal and small polymorphic caox crystals

Question 29

tx for caoxdd

Answer 29

• nsaids, colchicine, glucocorticoids, increased dialysis

- primary: liver transplant

Question 30

most critical diagnosis

Answer 30

infection

Question 31

normal and inflammatory and septic synovial fluid

Answer 31

normal: clear or pale straw, viscous, (+) string sign = hyaluronate
inflammatory: slightly cloudy, loss of viscosity, (-) string sign
septic: pus

Question 32

wbc counts

Answer 32

> 2000/uL = inflammatory / septic

>50,000 uL = septic