Gout/Pseudogout

Question 1

What is Gout/Pseudogout?

Answer 1

Deposition of Monosdoium urate crystls in joints leads to formation of gouty tophi, causing pain, redness and swelling, In pseudogout the crystals are made of calcium pyropohsopate instead of urate.

Question 2

What will you find on a history taking of Gout/Pseudogout?

Answer 2

Symptoms:
Acute swelling, Pain and redness of a single asymmetrical joint
Common sites - Great toe/thumb
Can also get tophi after an attack

Risk Factors:
Much more common in men
Reduced Urate excretion - Impaired renal function, hypertension, metabolic syndrome, diuretics, aspirin
increased Urate production - Alcohol, Sweeteners, Psoriasis, Warfarin
Risk Factors for Pseudogout - Hyperparathyroidism, Haemochromatosis, Diuretic use

Specific Questions to ask:
Common gout attack precipitants - trauma, surgery, starvation, infection, diuretics
Family Histroy
Previous self limiting attacks are good indication of gout
Can be associated with kidney stones, so ask about renal colic

Differentials:
Gout vs Pseudogout - Pseudogout less common in <50’s and more likely to affect wrist and knee joints.
Septic Arthritis - Same presentation, differed by aspiration
Trauma - History of trauma
Rheumatoid Arthritis - RA is more chronic, short attacks = gout
Reactive Arthritis - History of infection
Psoriatic Arthritis - Psoriasis

Question 3

What will you find on examination of Gout/Pseudogout?

Answer 3

In the affected joint:
Warm, red, and swollen.
Tenderness and limited range of movement due to pain.
Hard subcutaneous nodules (tophi) over the extensor surface of the affected joint,

Question 4

What investigations will you order in Gout/Pseudogout?

Answer 4

Bloods:
Serum Uric acid - Can be raised
Blood glucose/lipids - Gout commonly associated with metabolic syndrome
FBC - Rule out infection

Imaging:
Xray of affected joint - periarticular erosions

Special Tests:
Joint aspiration - Check for crystal levels and to rule out septic arthritis when cultured/checked for WCC
Birefringent studies if crystals detected - Negative = Gout and Positive = Pseudogout

Question 5

What is the treatment of Gout/Pseudogout?

Answer 5

Lifestyle:
Lose weight
Improve diet
Reduced alcohol
Increased fluid intake – improves reliability of uric acid urine excretion

Medical:
For Flare ups: Joint elevation and rest and use of cool packs

Gout
1st line = High dose NSAID + paracetamol
2nd line = Colchicine
3rd Line = Steroids 
Chronic Treatment - Allopurinol (Lowers uric acid levels) if >1 attack/year

Pseudogout
1st line = intra-articular corticosteroids + paracetamol
2nd line = Colchicine
During flare up swap any loop/thiazide diuretics used for blood pressure management for ACEi, ARB or calcium channel blockers if possible - Do not stop for oedema management