HYHO - Gout and Psuedogout

Question 1

Which nitrogen bases build up in gout? What sources are there for these?

Answer 1

Purines adenine and guanine produce uric acids in body.

Diet and NT synthesis/metabolism

Question 2

What is the degradation pathway for purines?

Answer 2

Inosine -> hypoxanthine -> xanthine -> uric acid
Xanthine oxidase helps w last two steps
Excreted from kidneys (70%) and gut

Question 3

Definition of gout

Answer 3

Intermittent, painful, inflammatory joint attack responding to uric acid crystals due to hyperuricemia

Question 4

Risk factors for gout

Answer 4

Male
Age (older)
Obesity
HTN
Hyperlipidemia
CV disease  
CKD
Medications 
Diet 
Lead exposure

Question 5

What two processes can cause hyperuricemia?

Answer 5

Overproduction of UA - hepatic metabolism or cell turnover

Under excretion of UA from kidneys or gut - main cause

Question 6

Clinical presentation of gout

Answer 6

Acute onset of joint pain, w max pain in 1st 24hrs
Often begin over night in acute flares
Joint is swollen, red, warm, and hurts

Question 7

What are the most commonly affected joints in gout?

Answer 7

1st MTP joint, knee joints, ankle joints

Question 8

What are provoking factors of gout?

Answer 8

ETOH consumption
Trauma
Inflammatory states
Dehydration

Question 9

What are gouty tophi?

Answer 9

Uric acid deposition w/in tissue

Question 10

What is the definitive test for gout?

Answer 10

Arthrocentesis of affected joint
send for cell count, culture, and gram stain
Use polarized light microscopy to look for monosodium urate crystals - needle shaped, negatively birfringent crystals

Question 11

Other than arthrocentesis, what tests should you order if gout is suspected?

Answer 11

Serum uric acid level
CBC w dif - look for left shift to rule out septic arthritis
X-ray isn’t helpful if acute, but could do for chornic to look for bony erosions

Question 12

Synovial fluid that is characteristic of gout?

Answer 12

WBCs is between 10,000-50,000/ mcg

infectious arthritis also has high WBC, but will use gram stain and fluid culture to rule out

Question 13

Tx of gout in patients with CKD

Answer 13

Be careful using NSAIDs and colchicine

Intra-articular injection or oral steroid are usually preferred

Question 14

Acute gouty flare treatment

Answer 14

NSAIDS
Colchicine - inhibits cytoskeletal fxn of neutrophils
Glucocorticoids -preferred for CKD

Question 15

Chronic gout tx

Answer 15

Xanthine oxidase inhibitors - wait two weeks after flare. allopurinol and febuxostate
Uricosuric agents to inhibit reabsorption of UA in PCT. Probenecid and Lesinuard
Uricase - converts UA to highly soluble allantonin

Question 16

Goal uric acid for patients with tophi and without?

Answer 16

With tophi - <6 mg/dl

W/o - <5 mg/dl

Question 17

Uricosuric agents

Answer 17

Probenecid and lesinurad

Question 18

Xanthine oxidase inhibitors

Answer 18

Allopurinol and febuxostate

Question 19

Prevention of gout

Answer 19

Avoid factors that contribute, like red meat, seafood, alcohol, high fructose corn syrup

Question 20

Pseudogout (Calcium Pyrophosphate Deposition)

Answer 20

Deposition of CPP crystal in and on cartilaginous surfaces can provoke acute inflammatory arthritis similar to gout

Question 21

Epidemiology of CPPD

Answer 21

> 60 tears
Osteoarthritis
Metabolic diseases - hyperparathyroidism, hemochromatosis, hypophosphatasia, hypomagnesemia

Question 22

Pathophysiology of CPPD

Answer 22

not really known, but probs pyrophosphate made by chondrocytes precipitates calcium forming CPP crystals

Question 23

Clinical presentation

Answer 23

Typically presents as monoarticular or oligoarticular arthritis.
Swollen, warn, painful
Knee and wrist joints, but not commonly the 1st MTP joint
Can last for weeks or months! Dif from acute gout

Question 24

What are provoking factors for pseudogout?

Answer 24

Surgery or acute illness

Question 25

Diagnosis of pseudo gout - definitive test

Answer 25

Arthrocentesis shows CPP crystals - rhomboid shaped and POSITIVELY birefringent under polarized light

Question 26

How can an xray support the dx of pseudogout?

Answer 26

Find chondrocalcinosis (not specific to CPPD)

Question 27

Treatment of pseudogout

Answer 27

NSAIDS
Colchicine
Intra-articular glucocorticioid injection or oral prednisone
Tx underlying metabolic dz

Question 28

Osteopathic considerations for gout - ew

Answer 28

Autonomic innervation
Kidney PNS is T10-T11, PNS is vagus nerve
UE: SNS T2-T7
LE: SNS T11

Question 29

Metabolic/immune for pseudogout and gout

Answer 29

Arthrocentesis
Uric acid levels
Renal function and renal dose medications
Caution with systemic steroid use in diabetics - check glucose more often
Consider stopping thiazide if recurrent gout (increases levels of UA)

Question 30

Behavioral of pseudogout/gout

Answer 30

Dietary changes. avoid red meat, seafood, alcohol