Gout, pseudogout...

Question 1

etiology of gout

Answer 1

monosodium urate cystals precipitate within join and surrounding tissue space –> inflammatory needle like pain

Question 2

patient presents with severe pain in great toe MTP. You notice redness and swelling. You predict this patient is suffering from gout..What is your next step

Answer 2

GOLD STANDARD: arthrocentesis (send fluid for culture and gram stain to r/o infection)

• for gout = negatively birefringent monosodium urate crystals
• 24 hour urinary uric acid secretion: overproducers >800 mg/dl, underexcreters ,700 mg/dl (not best for dx)

Question 3

what would radiographic evidence of gout consist of

Answer 3

joint erotion, rat bite appearance, punched out erosions

Question 4

List the stages of a gout attack

Answer 4

stage 1: asymptomatic hyperuricemia
stage 2: acute gouty arhritis triggered by acute change in uric acid
stage 3: intercritical gout/intermittent attacks
Stage 4: chronic tophaceous gout

Question 5

Types of gout…

Answer 5

1. Primary Hyperuricemia = idiopathic overproduction uric acid
2. Secondary hyperuricemia: either
   a) overproduction of uric acid due to enzyme defect, malignancy, obesity, psoriasis, drugs etc
   b) under excretion of uric acid (90%) due to renal insufficiency, diuretics, lead nephropathy, acidosis (DM, EtOH)

Question 6

treatment for stage 1 (acute stage) of gout attack

Answer 6

first line = NSAIDS specifically INDOMETHACIN (indomethacin also used for ankylosing spondylosis); may do intra articular steroid injection if r/o infection, oral steroids
*second line = COLCHICINE: back!, use at lower dose during acute attack, can be used for prevention as well to reduce inflammation and pain (not helpful for decreasing uric acid or bone damage)

Question 7

tx for stage 2/3 (prophylaxis to prevent flares and lowering excess uric acid stores)

Answer 7

overproducers = ALLOPURINOL (watch hypersensitivity)

• under excretors: PROBENECID
• new med: FEBUXOSTATE (good for over producers if impaired renal function)

Question 8

risks for gout

Answer 8

obesity, HTN, DM, family hx, alcohol/yeast, hospitalization, transplants, acidotic state, post menopause, high purine diet (organ meats, anchovies, mushrooms, spinach, asparagus, cauliflower, beans, seafood)

Question 9

what lab result differentiates Pseudogout from gout

Answer 9

synovial fluid aspiration in PSEUDO reveals POSITIVELY birefringent crystal, gout reveals NEG birefringent crystals

*note: no specific serum study for pseudogout, dx based on fluid analysis and xray revealing chondrocalcinosis

Question 10

what is the etiology of pseudogout

Answer 10

SYNOVITIS due to build up of calcium pyrophosphate dihydrate crustals (CPPD) –> chondrocalcinosis (cystal deposits into synovial tissue)

Question 11

A patient has acute onset of erythema pain and swelling in LARGE joints (wrist, hips, shoulders, ankles, elbows). Primary Dx and why

Answer 11

Pseudogout bc in large joints (gout is more in a single smaller joint ie MCP)
**50% pseudogout cases affect Knees

Question 12

What other diseases are associated with pseudogout

Answer 12

hyperparathyroidism, hypothyroidism, hypophosphatemia, hypomagnesemia, OA, joint trauma

Question 13

xray reveals evidence of calcium deposition (see punctate and linear radiodensities in cartilage, ligaments, joints) and osteophytes. Pt has positively birefringent crystals in synovial fluid and an elevated WBW. Dx?

Answer 13

Dx: pseudogout
tx :treat underlying cause, reduce pain (joint aspiration), intra articular steroid, NSAIDS, colcincine, joint immobilization, ice pack
PROPHYLAXIS = colchicine

Question 14

Pt has complaints of fever, fatigue, joint pain, head ache and rash. What studies might you order

Answer 14

ESR, ANA (subtypes: anti-dsDNA, anti-smith Ab) antiphopholipid Ab

OTher:
*checking for SLE

Question 15

Lab results reveal +ANA. What diseases are consistent with this result

Answer 15

95% of SLE cases, 70% scleroderma, 30-40% RA, 60% sjogren

Question 16

pt has +ANA, what other lab results would help dx this patient with SLE

Answer 16

+anti-dsDNA and +anti-smith (subtypes of ANA), +antiphospolipid Ab (thrombocytopenia)

• urinalysis with microscopy revealing pro/cell casts bc glomeruli damage,
• depressed complement levels (due to SLE immune complexes)

Question 17

Name the eleven dx guidelines for SLE. How many will confirm dx?

Answer 17

• need 4/11
  1. Malar (butterfly) rash)
  2. +ANA
  3. +anti-sm, anti-dsDNA, antiphospholipid Ab
  4. discoid rash
  5. photosensitivity rash
  6. mucosal ulcers
  7. polyarthritis
  8. serositis
  9. renal disorders
  10. neuro disorders/HA/seizures
  11. Hematologic disorders

Question 18

tx for SLE

Answer 18

NSAIDS
antimalarials (hydroxycloroquine (plaquenil))
corticosteroids (topical, intradermal)
decrease sun exposure
immunosuppressive meds (methotrexate)

Question 19

Tx for Lupus nephritis

Answer 19

cyclphosphamide, methylprednisolone

Question 20

tx for CNS involvement SLE

Answer 20

antipsychotics, anticonvulsants

Question 21

tx thrombocytopenia SLE

Answer 21

corticosteroids, danazol

Question 22

tx if +antiphospholipid Ab

Answer 22

warfarin, heparin

Question 23

other extra manifestations of SLE

Answer 23

non specific fever, fatigue, wt. loss, anemia, visual changes (retinal vasculitis), raynauds phenom, recurrent miscarriages, hair loss, edema, effusions

Question 24

Prognosis SLE

Answer 24

dep on severity (worse with Renal and CNS)
*infectious disease responsible for 29% death
10 yr survival in more than 90%

Question 25

etiology of SLE

Answer 25

autoantibodies to nuclear and cytoplasmic antigens destroy cells resulting in tissue damage

*antibody, antigen complexes deposited in tissue, small vessel walls, and basement membrane resulting in inflammation

Question 26

Pt has positive anti-histone antibodies but is negative for anti-dsDNA and anti-Sm. They complain of arthralgia, myalgia, malaise, and a rash. They take procainamide x 2 mth. Dx and tx?

Answer 26

drug induced SLE

tx: d/c drug, administer steroids

Question 27

Pt indicates dry mouth and decreased tears in addition to fingers that freq turn white, myalgia, joint pain and hx of chrons. Primary dx? what labs would confirm dx?

Answer 27

Dx: sjogerns
Labs: +Rf, +ANA, CBC anemia of chronic disease

Question 28

you determine pt has Sjogrens based off sx and labs indicating +Rf, +ANA, CBC anemia of chronic disease. How would you differentiate bw primary sjogren and sjogren related to SLE/RA

Answer 28

of the +ANA, anti SSA or SSB would indicate PRIMARY

anti SSC would indigate sjogren related to SLE/RA