Gout vs pseudo gout

Question 1

What are the features of gout?

Answer 1

• Intense pain, swelling and erythema of (usually) a single joint
• Most commonly affects first metatarso-phalangeal joint

Question 2

What joints can gout affect?

Answer 2

• First metatarsophalangeal joint (big toe) most common
• Also ankle, wrist, and knee
• Rarely affects more central joints e.g. hip or spine

Question 3

What investigations may be used for gout?

Answer 3

• Fine needle joint aspiration
• X-ray
• Serum uric acid 2 weeks after attack (not done during attack as may be high, low, or normal)

Question 4

What are some predisposing factors for gout?

Answer 4

• Thiazide diuretics
• Lead toxicity
• CKD
• Low dose aspirin
• Diet high in purines (red meat, oily fish, shellfish, beer)
• Metabolic syndrome
• Lesch-Nyhan syndrome

Question 5

What is the management of acute gout?

Answer 5

• NSAIDs or colchicine first line
• Oral steroids if both are contraindicated
• Intra-articular steroid injection may also be given
• Continue urate lowering therapy (but don’t commence)

Question 6

What is the management following acute gout/management of chronic gout?

Answer 6

• Urate lowering therapy after 2-4 weeks: allopurinol (first line) or febuxostat (second line)
• Lifestyle modifications: lose weight, reduce alcohol, avoid purine rich foods

Question 7

What are important considerations when using colchicine?

Answer 7

• Use carefully in renal impairment
• Diarrhoea is common side effect

Question 8

What are the features of pseudogout?

Answer 8

Monoarthropathy most commonly affecting knees, wrists and shoulders

Question 9

What are the risk factors for pseudogout?

Answer 9

• Haemochromatosis
• Hyperparathyroidism
• Low magnesium, low phosphate
• Acromegaly, Wilson’s disease

Question 10

What investigations may be done for pseudogout?

Answer 10

• Fine needle aspiration
• X-ray

Question 11

What will fine needle aspiration show in gout and pseudogout?

Answer 11

• Gout: needle shaped negatively birefringent monosodium rate crystals
• Pseudogout: rhomboid shaped positively birefringent calcium pyrophosphate crystals

Question 12

What will X-ray show in gout vs pseudogout?

Answer 12

• Gout: joint effusion (early), well-defined lesions with sclerotic margin sin juxta-articular distribution
• Pseudogout: chondrocalcinosis