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Clin Med Exam 3 (Lauren) > Gout, Pseudogout, Reactive Arthritis, Ankylosing Spondylitis > Flashcards

Gout, Pseudogout, Reactive Arthritis, Ankylosing Spondylitis Flashcards

1
Q

What is the cardinal feature of gout

A

Hyperuricemia

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2
Q

Is gout an inflammatory arthritis?

A

Yes

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3
Q

Where does uric acid come from?

A

It is a product of the breakdown of purines

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4
Q

What are the two ways somebody can have hyperuricemia?

A

Underexcreter (most common)

Overproducer

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5
Q

What are the serum uric acid levels that qualify as hyperuricemia?

A

over 7 in males

Over 6 in females

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6
Q

How does an overproducer get hyperuricemia?

A

Increased purine consumption (diet)

High cell turnover (psoriasis, etc)

Inherited enzyme defects

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7
Q

How does an underexcreter get hyperuricemia?

A

Renal insufficiency

Diuretics

Volume depletion

Lead nephropathy (kidney injury)

(Uric acid is excreted by the kidney)

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8
Q

Who is more likely to get gout?

A

Males

Advanced age

Pacific Islanders

Genetic mutation

Obese

Diets rich in meat and seafood

EtOH

Fructose

Diuretics

Transplant recipients

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9
Q

What are the 4 stages of gout?

A
  1. Asymptomatic hyperuricemia
  2. Acute gouty arthritis (first attack)
  3. Intercritical gout (no symptoms)
  4. Chronic gouty arthritis (tophaceous gout)-joint destruction and tophi
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10
Q

Does everyone with hyperuricemia develop gout?

A

No, only 15% do

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11
Q

Does everyone who gets acute gouty arthritis (first attack) end up having another attack?

A

No, 5-10% will never have another

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12
Q

During intercritical gout (3rd stage) does the pt have symptoms?

A

No, it is an asymptomatic interval b/w attacks

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13
Q

Are tophi present in all phases of gout?

A

No, they only appear in late stage 4 gout (chronic gouty arthritis)

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14
Q

What are tophi?

A

White, chalky bumps that are dense collections of MSU crystals ***

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15
Q

What do tophi represent?

A

The duration and severity of hyperuricemia***

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16
Q

When do tophi appear?

A

10 years after 1st attack if the gout is left untreated

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17
Q

Does chronic gouty arthritis (Stage 4 gout) end up with bone and cartilage erosion?

A

Yes.

No other stage has erosion

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18
Q

Can gout affect the kidneys?

A

Yes. Can cause stones and nephropathy

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19
Q

Where are acute gout attacks located usually?

A

ONE joint

1st MTP joint “Podagra”

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20
Q

Will gout attacks go away on their own?

A

Yes in about 2 weeks without treatment. Patient will be miserable though.

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21
Q

What triggers an acute gout flare?

A

Increases OR decreases in urate levels

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22
Q

Can allopurinol trigger an acute gout flare?

A

Yes because it can lower urate levels

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23
Q

When do acute gout attacks usually hit patients?

A

Rapid onset at night

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24
Q

What is an important ddx to rule out when a pt is having an acute gout attack?

A

Celllulitis in their big toe

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25
Q

What will you see on an X-ray in advanced gout?

A

Bony erosions “punched out” with “rat bite” erosions.

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26
Q

What will you see on an x ray of early gout?

A

Soft tissue swelling around affected joint

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27
Q

What will you see on ultrasound of a gout joint?

A

Double contour sign

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28
Q

What do you need to do to make a definitive diagnosis of gout?

A

Aspiration of the joint and then do a culture, gram stain, and microscopic analysis of the fluid.

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29
Q

What will you see under the microscope if a patient has gout?

A

Monosodium Urate Crystals that are:

Needle shaped

Negatively Birefringent
*********

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30
Q

Is serum Uric Acid levels a good diagnostic study for gout?

A

No, because sUA may be normal during an attack.

It’s most accurate 2 weeks after the flare subsides.

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31
Q

When would you do a 24h URINARY Uric Acid study?

A

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

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32
Q

After the 1st gout attack, what of you need to talk to the pt about?

A

Weight loss

Diet

Smoking

Eliminating nonessential drugs that cause hyperuricemia

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33
Q

Would we treat someone with asymptomatic hyperuricemia?

A

Only if they were produced a shit load of uric acid >1100mg/dL

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34
Q

How do you treat an acute gout attack?

A

Treat the Pain and Inflammation

  • NSAIDS, steroids, or colchicine
  • don’t mess with their allopurinol

(NSAIDS are best if their kidneys can handle it)

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35
Q

What NSAIDS are recommended for an acute gout attack?

A

Indomethacin or Naproxen

Lower dose after significant pain relief, and stop altogether 2-3 days after pain goes away

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36
Q

When is colchicine most effective at treating the pain of an acute gout attack?

A

When it’s started within 36 hrs of onset

Discontinue 2-3 days after sx go away

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37
Q

What is a big side effect of colchicine?

A

Diarrhea

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38
Q

Who should be treated with urate lowering therapy?

A

Established diagnosis of gout
AND:
Tophi

2+ attacks/yr

CKD stage II+

Hx of kidney stones

39
Q

What are the Xanthine Oxidase Inhibitors that are used to lower urate?

A

Allopurinol

Febuxostat

40
Q

What are the uricosuric agents that are used to lower urate?

A

Probenecid

Lesinurad

41
Q

Would you be giving your patient Pegloticase for their gout?

A

No, it is an IV drug that rheumatology would handle

42
Q

How does allopurinol lower urate?

A

It decreases uric acid synthesis

43
Q

Is allopurinol good for overproducers or underexcreters?

A

BOTH

44
Q

What is a major side effect of allopurinol?

A

Severe cutaneous reactions, aka SJS or TENS

45
Q

Is someone is HLA-B 5801 positive would we give them allopurinol?

A

No because of the risk of SJS or TENS

46
Q

What is the difference between allopurinol and Febuxostat? They are both xanthine oxidase inhibitors!

A

Febuxostat is more expensive

47
Q

Is probenecid good for overproducers or underexcreters?

A

Underexcreters……with good kidney function. You wouldn’t want to give this to someone with shitty kidneys

48
Q

How do you initiate urate-lowering therapy?

A

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

49
Q

What is the other name for pseudogout?

A

Acute CPP Crystal Arthritis

A form of CPP deposition disease

50
Q

What is the characterizing feature of pseudogout?

A

CPP (calcium pyrophospate) crystal formation and deposition

51
Q

Who is most likely to get pseudogout/acute CPP crystal arthritis?

A

Old people of any gender

Difference from gout, where M>F and 30-60

52
Q

Are hemochromatosis and hyperparathyroidism associated with pseudogout?

A

Yes

53
Q

In a severe, acute inflammation of CPP Crystal arthritis/pseudogout, which joint is usually affected?

A

Knee.

Can also be wrists, shoulders, ankles, feet, and elbows

54
Q

What can provoke attacks of pseudogout?

A

Trauma

Surgery

Severe illness

55
Q

What will you see on an x-ray of someone with CPP crystal arthritis/pseudogout?

A

Chondrocalcinosis (“cartilage calcification”)

Punctate and Linear Radiodensities

56
Q

What will you see under the microscope if you aspirate a joint of someone with pseudogout/CPP crystal arthritis?

A

Positively Birefringenet CPP Crystals

Rhomboid shaped crystals
**

P for positive
P for pseudogout

57
Q

How do you treat an acute attack of CPP crystal arthritis/pseudogout?

A

NSAIDS**

Steroid injection (as long as you r/o infection)

Colchicine

Ice, rest, etc

58
Q

What is the prophylactic treatment to prevent attacks of CPP crystal arthritis/psuedogout?

A

Colchicine

59
Q

What is spondyloarthritis?

A

A family* of inflammatory rheumatic diseases that cause arthritis

60
Q

What are the 2 classifications of Spondyloarthritis?

A

Axial disease (ex. Ankylosing spondylitis)

Peripheral disease
Ex. Psoriatic arthritis, reactive arthritis

61
Q

What is enthesitis?

A

Inflammation of entheses- the site of insertion of ligaments, tendons, etc into bone

62
Q

What is the most common clinical manifestation of enthesitis?

A

Heel pain- where Achilles’ tendon or plantar fasciae insert into the calcaneus

63
Q

Is enthesitis associated with both axial and peripheral spondyloarthritis?

A

Yes

64
Q

What is reactive arthritis?

A

An ACUTE inflammatory arthritis that is triggered by a preceding GI or genitourinary infection
** ON EXAM*

65
Q

What kinds of infections can trigger reactive arthritis?

A

GI: shigella, salmonella, yersinia, campylobacter

GU: chlamydia

66
Q

Is reactive arthritis associate with HLA-B27?

A

Yes

67
Q

Who usually gets reactive arthritis?

A

Young adults of both genders

With a genetic predisposition via HLA B27

68
Q

How will reactive arthritis present?

A

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

69
Q

What are some of the other symptoms that someone with reactive arthritis may present with?

A

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

70
Q

What percentage of pts with reactive arthritis will have a positive HLA-B27 antigen?

A

30-50%

71
Q

If you analyzed the synovial fluid in a patient with reactive arthritis, what would you find?

A

Inflammation

No crystals or infection

72
Q

How do you manage reactive arthritis?

A

NSAIDS** mainstay

Refer to rheumatology

Refer to ophthalmology if they can’t see

73
Q

Name it:
Oligoarthritis, conjunctivitis, urethritis

Following a diarrheal illness or STD

Positive HLA-B27

Mucocutaneous lesions

A

REACTIVE ARTHRITIS ***

74
Q

What is Ankylosing spondylitis?

A

Chronic inflammatory disease of the axial skeleton

Back pain and progressive stiffness of the spine

75
Q

Is entheses seen in Ankylosing spondylitis as well as reactive arthritis?

A

Yes

76
Q

What joints are most commonly affected in Ankylosing spondylitis?

A

SI joints

Spinal facet joints

(Also hips, shoulders, peripheral joints, and entheses)

77
Q

Who is more likely to get Ankylosing spondylitis?

A

White

Male

Young adults! 20-30 yrs old

78
Q

What should you keep in mind when you see a young adult with chronic back pain, and you think they are drug seeking?

A

Could be Ankylosing spondylitis

79
Q

Is there a strong hereditary component to Ankylosing spondylitis?

A

YES

Over 85% of patients have HLA-B27

80
Q

What is the disease process of Ankylosing spondylitis?

*****

A
  1. Enthesitis with chronic inflammation (remember enthesitis is inflammation where tendon meets bone, not always in heels)
  2. Structural damage
  3. New bone formation (too much bone)
  4. Ankylosis (fusion)

THIS WAS STARRED*

81
Q

What joints does Ankylosing spondylitis usually start in?

A

SI joints and then moves proximally

82
Q

What is it called in Ankylosing spondylitis when the outer ligaments and annulus fibrosis of the spine ossify?

A

Formation of syndesmophytes

83
Q

What is Bamboo spine?

A

Inflammation caused new bone formation that bridged the vertebrae together….loss of intervertbral space

(Seen in advanced Ankylosing spondylitis)

84
Q

Is Ankylosing spondylitis acute or insidious onset?

A

Insidious onset of low back pain (SI Joints)

85
Q

How does the pain of Ankylosing spondylitis present?

A

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

86
Q

Are syndesmophytes, sacroiliitis, and spinal fusion seen in inflammatory or mechanical back pain?

A

Inflammatory (i.e., Ankylosing spondylitis)

87
Q

Are osteophytes, disc space narrowing, and vertebral malalignment seen with inflammatory back pain, or mechanical back pain?

A

Mechanical (like a car accident)

88
Q

Would you expect to see hyperkyphosis and loss of the lumbar curve with Ankylosing spondylitis

A

Yes

89
Q

What is the schober test and what is it used for?

A

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.

90
Q

What are some of the extra articular manifestations of Ankylosing spondylitis?

A

Anterior uveitis (eye problem)

IBD

psoriasis

Fatigue

Sleep disturbance

91
Q

What would you see in labs for Ankylosing spondylitis?

A

Normocytic-normochromic anemia

Elevate ESR and CRP

Positive HLA-B27

92
Q

What would you see on x-ray of Ankylosing spondylitis

A

Sacroiliitis***

Bamboo spine*** (late AS)

93
Q

What is the treatment for Ankylosing spondylitis

A

NSAIDS*****

Immunosuppressants

Stop smoking

DAILY EXERCISE *****

94
Q

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

A

Ankylosing Spondylitis

Clin Med Exam 3 (Lauren) (7 decks)

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