Gout, Pseudogout, Reactive Arthritis, Ankylosing Spondylitis Flashcards
What is the cardinal feature of gout
Hyperuricemia
Is gout an inflammatory arthritis?
Yes
Where does uric acid come from?
It is a product of the breakdown of purines
What are the two ways somebody can have hyperuricemia?
Underexcreter (most common)
Overproducer
What are the serum uric acid levels that qualify as hyperuricemia?
over 7 in males
Over 6 in females
How does an overproducer get hyperuricemia?
Increased purine consumption (diet)
High cell turnover (psoriasis, etc)
Inherited enzyme defects
How does an underexcreter get hyperuricemia?
Renal insufficiency
Diuretics
Volume depletion
Lead nephropathy (kidney injury)
(Uric acid is excreted by the kidney)
Who is more likely to get gout?
Males
Advanced age
Pacific Islanders
Genetic mutation
Obese
Diets rich in meat and seafood
EtOH
Fructose
Diuretics
Transplant recipients
What are the 4 stages of gout?
- Asymptomatic hyperuricemia
- Acute gouty arthritis (first attack)
- Intercritical gout (no symptoms)
- Chronic gouty arthritis (tophaceous gout)-joint destruction and tophi
Does everyone with hyperuricemia develop gout?
No, only 15% do
Does everyone who gets acute gouty arthritis (first attack) end up having another attack?
No, 5-10% will never have another
During intercritical gout (3rd stage) does the pt have symptoms?
No, it is an asymptomatic interval b/w attacks
Are tophi present in all phases of gout?
No, they only appear in late stage 4 gout (chronic gouty arthritis)
What are tophi?
White, chalky bumps that are dense collections of MSU crystals ***
What do tophi represent?
The duration and severity of hyperuricemia***
When do tophi appear?
10 years after 1st attack if the gout is left untreated
Does chronic gouty arthritis (Stage 4 gout) end up with bone and cartilage erosion?
Yes.
No other stage has erosion
Can gout affect the kidneys?
Yes. Can cause stones and nephropathy
Where are acute gout attacks located usually?
ONE joint
1st MTP joint “Podagra”
Will gout attacks go away on their own?
Yes in about 2 weeks without treatment. Patient will be miserable though.
What triggers an acute gout flare?
Increases OR decreases in urate levels
Can allopurinol trigger an acute gout flare?
Yes because it can lower urate levels
When do acute gout attacks usually hit patients?
Rapid onset at night
What is an important ddx to rule out when a pt is having an acute gout attack?
Celllulitis in their big toe
What will you see on an X-ray in advanced gout?
Bony erosions “punched out” with “rat bite” erosions.
What will you see on an x ray of early gout?
Soft tissue swelling around affected joint
What will you see on ultrasound of a gout joint?
Double contour sign
What do you need to do to make a definitive diagnosis of gout?
Aspiration of the joint and then do a culture, gram stain, and microscopic analysis of the fluid.
What will you see under the microscope if a patient has gout?
Monosodium Urate Crystals that are:
Needle shaped
Negatively Birefringent
*********
Is serum Uric Acid levels a good diagnostic study for gout?
No, because sUA may be normal during an attack.
It’s most accurate 2 weeks after the flare subsides.
When would you do a 24h URINARY Uric Acid study?
If you’re considering uricosuric therapy.
<800mg of uric acid in their pee means they’re an underexcreter and you can give them uricosuric therapy
After the 1st gout attack, what of you need to talk to the pt about?
Weight loss
Diet
Smoking
Eliminating nonessential drugs that cause hyperuricemia
Would we treat someone with asymptomatic hyperuricemia?
Only if they were produced a shit load of uric acid >1100mg/dL
How do you treat an acute gout attack?
Treat the Pain and Inflammation
- NSAIDS, steroids, or colchicine
- don’t mess with their allopurinol
(NSAIDS are best if their kidneys can handle it)
What NSAIDS are recommended for an acute gout attack?
Indomethacin or Naproxen
Lower dose after significant pain relief, and stop altogether 2-3 days after pain goes away
When is colchicine most effective at treating the pain of an acute gout attack?
When it’s started within 36 hrs of onset
Discontinue 2-3 days after sx go away
What is a big side effect of colchicine?
Diarrhea
Who should be treated with urate lowering therapy?
Established diagnosis of gout
AND:
Tophi
2+ attacks/yr
CKD stage II+
Hx of kidney stones
What are the Xanthine Oxidase Inhibitors that are used to lower urate?
Allopurinol
Febuxostat
What are the uricosuric agents that are used to lower urate?
Probenecid
Lesinurad
Would you be giving your patient Pegloticase for their gout?
No, it is an IV drug that rheumatology would handle
How does allopurinol lower urate?
It decreases uric acid synthesis
Is allopurinol good for overproducers or underexcreters?
BOTH
What is a major side effect of allopurinol?
Severe cutaneous reactions, aka SJS or TENS
Is someone is HLA-B 5801 positive would we give them allopurinol?
No because of the risk of SJS or TENS
What is the difference between allopurinol and Febuxostat? They are both xanthine oxidase inhibitors!
Febuxostat is more expensive
Is probenecid good for overproducers or underexcreters?
Underexcreters……with good kidney function. You wouldn’t want to give this to someone with shitty kidneys
How do you initiate urate-lowering therapy?
wait 2 weeks until gout flare has gone away
Then Treat to Target of sUA of 6mg or less (5mg for tophaceous gout)
Once at goal, monitor sUA levels every few months, then once a year
What is the other name for pseudogout?
Acute CPP Crystal Arthritis
A form of CPP deposition disease
What is the characterizing feature of pseudogout?
CPP (calcium pyrophospate) crystal formation and deposition
Who is most likely to get pseudogout/acute CPP crystal arthritis?
Old people of any gender
Difference from gout, where M>F and 30-60
Are hemochromatosis and hyperparathyroidism associated with pseudogout?
Yes
In a severe, acute inflammation of CPP Crystal arthritis/pseudogout, which joint is usually affected?
Knee.
Can also be wrists, shoulders, ankles, feet, and elbows
What can provoke attacks of pseudogout?
Trauma
Surgery
Severe illness
What will you see on an x-ray of someone with CPP crystal arthritis/pseudogout?
Chondrocalcinosis (“cartilage calcification”)
Punctate and Linear Radiodensities
What will you see under the microscope if you aspirate a joint of someone with pseudogout/CPP crystal arthritis?
Positively Birefringenet CPP Crystals
Rhomboid shaped crystals
**
P for positive
P for pseudogout
How do you treat an acute attack of CPP crystal arthritis/pseudogout?
NSAIDS**
Steroid injection (as long as you r/o infection)
Colchicine
Ice, rest, etc
What is the prophylactic treatment to prevent attacks of CPP crystal arthritis/psuedogout?
Colchicine
What is spondyloarthritis?
A family* of inflammatory rheumatic diseases that cause arthritis
What are the 2 classifications of Spondyloarthritis?
Axial disease (ex. Ankylosing spondylitis)
Peripheral disease
Ex. Psoriatic arthritis, reactive arthritis
What is enthesitis?
Inflammation of entheses- the site of insertion of ligaments, tendons, etc into bone
What is the most common clinical manifestation of enthesitis?
Heel pain- where Achilles’ tendon or plantar fasciae insert into the calcaneus
Is enthesitis associated with both axial and peripheral spondyloarthritis?
Yes
What is reactive arthritis?
An ACUTE inflammatory arthritis that is triggered by a preceding GI or genitourinary infection
** ON EXAM*
What kinds of infections can trigger reactive arthritis?
GI: shigella, salmonella, yersinia, campylobacter
GU: chlamydia
Is reactive arthritis associate with HLA-B27?
Yes
Who usually gets reactive arthritis?
Young adults of both genders
With a genetic predisposition via HLA B27
How will reactive arthritis present?
Joint pain on ONE side, usually in the knees, ankles, or feet
1-4 wks following the inciting infections
May also have axial/peripheral musculoskeletal symptoms or extra-articular symptoms
What are some of the other symptoms that someone with reactive arthritis may present with?
Peripheral arthritis
Enthesitis
Sausage fingers (dactylitis)
Low back pain (cant climb tree)
Conjunctivitis (cant see)
Urethritis (cant pee)
Nail changes
Keratoderma blennorrhagicum (thickened pustules)
Oral ulcers
What percentage of pts with reactive arthritis will have a positive HLA-B27 antigen?
30-50%
If you analyzed the synovial fluid in a patient with reactive arthritis, what would you find?
Inflammation
No crystals or infection
How do you manage reactive arthritis?
NSAIDS** mainstay
Refer to rheumatology
Refer to ophthalmology if they can’t see
Name it:
Oligoarthritis, conjunctivitis, urethritis
Following a diarrheal illness or STD
Positive HLA-B27
Mucocutaneous lesions
REACTIVE ARTHRITIS ***
What is Ankylosing spondylitis?
Chronic inflammatory disease of the axial skeleton
Back pain and progressive stiffness of the spine
Is entheses seen in Ankylosing spondylitis as well as reactive arthritis?
Yes
What joints are most commonly affected in Ankylosing spondylitis?
SI joints
Spinal facet joints
(Also hips, shoulders, peripheral joints, and entheses)
Who is more likely to get Ankylosing spondylitis?
White
Male
Young adults! 20-30 yrs old
What should you keep in mind when you see a young adult with chronic back pain, and you think they are drug seeking?
Could be Ankylosing spondylitis
Is there a strong hereditary component to Ankylosing spondylitis?
YES
Over 85% of patients have HLA-B27
What is the disease process of Ankylosing spondylitis?
*****
- Enthesitis with chronic inflammation (remember enthesitis is inflammation where tendon meets bone, not always in heels)
- Structural damage
- New bone formation (too much bone)
- Ankylosis (fusion)
THIS WAS STARRED*
What joints does Ankylosing spondylitis usually start in?
SI joints and then moves proximally
What is it called in Ankylosing spondylitis when the outer ligaments and annulus fibrosis of the spine ossify?
Formation of syndesmophytes
What is Bamboo spine?
Inflammation caused new bone formation that bridged the vertebrae together….loss of intervertbral space
(Seen in advanced Ankylosing spondylitis)
Is Ankylosing spondylitis acute or insidious onset?
Insidious onset of low back pain (SI Joints)
How does the pain of Ankylosing spondylitis present?
Insidious onset of low back pain (SI joints)
Pain and stiffness
Worse in the morning and with inactivity
Better when moving
Fatigue
Radiates into buttocks
Pain for >3 months
Are syndesmophytes, sacroiliitis, and spinal fusion seen in inflammatory or mechanical back pain?
Inflammatory (i.e., Ankylosing spondylitis)
Are osteophytes, disc space narrowing, and vertebral malalignment seen with inflammatory back pain, or mechanical back pain?
Mechanical (like a car accident)
Would you expect to see hyperkyphosis and loss of the lumbar curve with Ankylosing spondylitis
Yes
What is the schober test and what is it used for?
Used for Ankylosing spondylitis.
Draw 2 points on spine 15cm apart, pt bends forward and the distance should increase to 20cm or more. If it doesnt, that indicated spinal fusion.
What are some of the extra articular manifestations of Ankylosing spondylitis?
Anterior uveitis (eye problem)
IBD
psoriasis
Fatigue
Sleep disturbance
What would you see in labs for Ankylosing spondylitis?
Normocytic-normochromic anemia
Elevate ESR and CRP
Positive HLA-B27
What would you see on x-ray of Ankylosing spondylitis
Sacroiliitis***
Bamboo spine*** (late AS)
What is the treatment for Ankylosing spondylitis
NSAIDS*****
Immunosuppressants
Stop smoking
DAILY EXERCISE *****
Name it:
Inflammatory back pain that is worse with inactivity and better with movement
Back stiffness
Young males
Positive HLA-B27
Bamboo spine
Anterior uveitis
NSAIDs are first line tx
Ankylosing Spondylitis
