gout and pseudogout Flashcards
Inflammatory and non-inflammatory causes of monoarthiritis
Non-inflammatory
- trauma
- haemarthrosis
- avascular necrosis
- sickle-cell disease
Inflammatory
- septic arthiritis
- neisserial
- gout
- pseudogout
- reactive arthiritis
- spondyloarthiritis
- lyme disease
What is the most common inflammatory disease?
Gout
Reasons for gout
Urate formation
–> overproduction of purine
1) exogenous: protein and meat
2) endogenous: breakdown of cells
–> underexcretion of purine (more common)
1) drugs
2) genetic factors
3) kidney disease
pathogenesis for gout
Urate crystals are phagocytosed
by macrophages.
2. This activates inflammatory
mediators that release IL-1.
3. IL-1 recruit neutrophils, which in
turn release other cytokines, free
radicals and proteases.
4. Neutrophils also phagocytose the
crystals which, together with the
macrophages damage the
membranes of the lysosomes
leading to the release of enzymes
Risk factors for gout
Age, Male, Obesity, Kidney Disease, Ethnicity, Genetic Polymorphisms
Complications of gout
Hypertension, Renal disease, Urolithiasis, CV diseases, CV and renal mortality
What is acute gout attack?
1) Acute onset of severe joint inflammation
2) Usually monoarticular
3) First MTP joint 50% of time, midfoot, ankles, heel or knee
4) Intracellular urate crystals in synovial fluid
5) +/- fevers, chills, malaise
6) Resolves in 3-10 days
Diagnosis
1) Gold Standard - Strongly/ Negatively birefringent (very bright) Monosodium urate (needle-like) crystals in synovial fluid/tissue
2) Clinical diagnosis
- Typical pattern
- Maximum inflammation developed within one day
- Recurrent attacks
- Tophi
- Hyperuricemia
3) Radiograph (ONLY in advanced gout)
- gouty erosion is both destructive and hypertrophic, leading
to “overhanging edges”
- The joint space is often
preserved until very late in
the disease process
- punched out space in periarticular area
Uric acid < 300
What can reduce risk of gout?
Legumes, Soy, Grains
Treatment goals of gout
1) Terminate the acute flare as rapidly as possible
2) Protect against further attacks (prophylaxis) –> reduce the chance of crystal induced inflammation
3) Treat the hyperuricemia and prevent disease progression
1) provides long term correction of the metabolic problem
2) lower the serum urate sufficiently to deplete body urate pool
What are indications for urate lowering agents?
1) Tophi, multiple joints, radiographic
2) Urate nephrpathy or urolithiasis
3) Frequent attacks >= 2 /year
4) Chronic kidney disease
Presentation of Pseudogout
1) Chronic bilateral knee pain with acute swelling of (left/right) knee
2) Synovial fluid: abundant polymorphs and scattered macrophages
3) WBC 68220, g/s negative
4) Weakly positively birefringent + rhomboid shaped crystals, consistent with calcium pyrophosphate crystals are seen on polarized light microscopy
Pathogenesis of pseudogout
1) Alterations in levels or availability pyrophosphate, phosphate and calcium
2) Crystal shedding
3) Increasted ATP breakdown –> increased extracellular PPi
4) PPi + Ca –> CPPD in cartilage
CPDD
1) Sporadic, familial, metabolic (predominantly in elderly)
2) Asymptomatic chondrocalcinosis
—> observed in radiograph as linear or punctate calcifications are seen within the cartilage, particularly in the fibrocartilage and hyaline cartilage.
3) Acute, self-limiting synovitis (Acute CPP crystal arthritis or “pseudogout”)
4) Chronic arthopathy which shows an associate and an overlap –> OA
– target joints are knees wrists, shoulders and hips
– pseudoOA, pseudoRA, pseudoCharcot
Assessment of pseudogout
1) In patients < 50 yo
2) Secondary to:
- hyperparathyroidism,
- hypothyroidism,
- hypophosphatasia
- hemochromatosis
3) serum levels of thyroid hormone, parathyroid hormone and alkaline phosphatase, serum calcium, phosphate, iron and magnesium levels
Treatment
1) primary goals for treating CPPD is to control inflammation and prevent acute flares
2) not indicated for asymptomatic chondrocalcinosis
3) similar to treating acute gout
4) attention to comorbiditis in the elderly
5) hcq, mtx are tested but not commonly used
–> reduce joint stiffness and maintain mobility; such as exercise, weight reduction and wearing joint support aids.
CASE 15: A 50-year-old male, presented to the outpatient clinic with complaints of persistent severe pain
and swelling in his right ankle of three days duration. The symptoms started acutely three days
ago in the morning, limiting his ability to walk and perform daily activities. He had three other
episodes of right big toe pain and swelling in the past 6 months, which lasted for only one to two
days and recovered well after self medication with ibuprofen.
* The man has a history of hypertension, for which he has been on amlodipine 5 mg daily for the
past five years. He denies any history of diabetes, chronic kidney disease, or cardiovascular
events. His family history is notable for gout, as his father and older brother also suffer from the
condition. He is a non-smoker and consumes alcohol occasionally, typically 1-2 glasses of wine per
week.
* On physical examination, the man appeared in distress due to pain. His right ankle was visibly
swollen, erythematous, and warm to the touch. There was limited range of motion due to pain.
The left ankle and other joints were unremarkable. Vital signs were stable with a blood pressure
of 135/85 mmHg, heart rate of 78 bpm, and no fever.
What are the possible diagnoses for this man?
Diagnosis: Gout
Differential:
- Septic arthiritis (if inflammatory and monoarthirits always have this as differential)
- OA
- Ankle trauma
CASE 15: A 50-year-old male, presented to the outpatient clinic with complaints of persistent severe pain
and swelling in his right ankle of three days duration. The symptoms started acutely three days
ago in the morning, limiting his ability to walk and perform daily activities. He had three other
episodes of right big toe pain and swelling in the past 6 months, which lasted for only one to two
days and recovered well after self medication with ibuprofen.
* The man has a history of hypertension, for which he has been on amlodipine 5 mg daily for the
past five years. He denies any history of diabetes, chronic kidney disease, or cardiovascular
events. His family history is notable for gout, as his father and older brother also suffer from the
condition. He is a non-smoker and consumes alcohol occasionally, typically 1-2 glasses of wine per
week.
* On physical examination, the man appeared in distress due to pain. His right ankle was visibly
swollen, erythematous, and warm to the touch. There was limited range of motion due to pain.
The left ankle and other joints were unremarkable. Vital signs were stable with a blood pressure
of 135/85 mmHg, heart rate of 78 bpm, and no fever.
What complications do you anticipate in this condition and
how would you manage them?
1) Chronic gout
2) Kidney stone
3) Renal impairment
CASE 15: A 50-year-old male, presented to the outpatient clinic with complaints of persistent severe pain
and swelling in his right ankle of three days duration. The symptoms started acutely three days
ago in the morning, limiting his ability to walk and perform daily activities. He had three other
episodes of right big toe pain and swelling in the past 6 months, which lasted for only one to two
days and recovered well after self medication with ibuprofen.
* The man has a history of hypertension, for which he has been on amlodipine 5 mg daily for the
past five years. He denies any history of diabetes, chronic kidney disease, or cardiovascular
events. His family history is notable for gout, as his father and older brother also suffer from the
condition. He is a non-smoker and consumes alcohol occasionally, typically 1-2 glasses of wine per
week.
* On physical examination, the man appeared in distress due to pain. His right ankle was visibly
swollen, erythematous, and warm to the touch. There was limited range of motion due to pain.
The left ankle and other joints were unremarkable. Vital signs were stable with a blood pressure
of 135/85 mmHg, heart rate of 78 bpm, and no fever.
What is the most important procedure to confirm the likely
diagnosis?
1) Joint aspiration
2) Polarised microscopy
–> to send synovial fluid to look for crystals and culture in grown strain
CASE 15: A 50-year-old male, presented to the outpatient clinic with complaints of persistent severe pain
and swelling in his right ankle of three days duration. The symptoms started acutely three days
ago in the morning, limiting his ability to walk and perform daily activities. He had three other
episodes of right big toe pain and swelling in the past 6 months, which lasted for only one to two
days and recovered well after self medication with ibuprofen.
* The man has a history of hypertension, for which he has been on amlodipine 5 mg daily for the
past five years. He denies any history of diabetes, chronic kidney disease, or cardiovascular
events. His family history is notable for gout, as his father and older brother also suffer from the
condition. He is a non-smoker and consumes alcohol occasionally, typically 1-2 glasses of wine per
week.
* On physical examination, the man appeared in distress due to pain. His right ankle was visibly
swollen, erythematous, and warm to the touch. There was limited range of motion due to pain.
The left ankle and other joints were unremarkable. Vital signs were stable with a blood pressure
of 135/85 mmHg, heart rate of 78 bpm, and no fever.
What other prior symptom or current sign may help to
confirm the diagnosis?
1) Previous episodes of acute monoarthritis
2) Tophi
3) Hyperuricemia
CASE 15: A 50-year-old male, presented to the outpatient clinic with complaints of persistent severe pain
and swelling in his right ankle of three days duration. The symptoms started acutely three days
ago in the morning, limiting his ability to walk and perform daily activities. He had three other
episodes of right big toe pain and swelling in the past 6 months, which lasted for only one to two
days and recovered well after self medication with ibuprofen.
* The man has a history of hypertension, for which he has been on amlodipine 5 mg daily for the
past five years. He denies any history of diabetes, chronic kidney disease, or cardiovascular
events. His family history is notable for gout, as his father and older brother also suffer from the
condition. He is a non-smoker and consumes alcohol occasionally, typically 1-2 glasses of wine per
week.
* On physical examination, the man appeared in distress due to pain. His right ankle was visibly
swollen, erythematous, and warm to the touch. There was limited range of motion due to pain.
The left ankle and other joints were unremarkable. Vital signs were stable with a blood pressure
of 135/85 mmHg, heart rate of 78 bpm, and no fever.
What is the appropriate treatment plan?
1) NSAIDs
2) Colchines
3) Corticosteroids
(cuz acute –> do not increase urate lowering agents during the attack can keep it at current dose. for the first time, give a small dose and titrate it up)
Long term:
- lifestyle modifications
Who will need uric acid lowering therapy for gout?
!! look out for rash (hypersensitivity)
1) Gout attack more than 4 times a year
2) Tophaceous gout (goal: < 5 mg/dL)
not relevant if older patients or CKD (although urate can help CKD)
What drugs to avoid if patient has kidney failure?
Colchine and NSAIDS
When do you give probenecid?
1) If patient is allergic to alloupurinol
2) History of recent heart attack
