L07: Cystalline Disease

Question 1

What is gout

Answer 1

An inflammatory disease caused by the deposition of monosodium urate (MSU) crystals in the joint and other tissue

Question 2

What are formation of crystals a consequence of in gout

Answer 2

Hyperuricaemia: serum uric acid more than 6mg/dl

Deposits of MSU crystals known as to phi may form in and around joints but also elsewhere

Question 3

What are the causes of Hyperuricaemia

Answer 3

Decreased fractional excretion via kidneys
Increased ingestion: beer, fructose rich beverage
Increased degradation: high cell turn over in psoriasis, haemotological malignancy
Advancing age
Genetic mutations

Question 4

What are the local factors for MSU crystal deposition

Answer 4

Formation of uric acid crystals will depen on:
Concentration of urate
Articular hydration state
Temperature
Ph
Presence of extracellular matrix proteins

Question 5

What is the association between gout and osteoarthritis

Answer 5

The cartilage damage in osteoarthritis can exposure collagen fibres that can act as template to promote MSU crystal nucleation

Question 6

What are the clinical features of gout

Answer 6

There are 3 periods to gout:
Asymptomatic hyperurasemia
Acute attack of asymptomatic intervals
Chronic gout

Question 7

What is acute gout characterised by

Answer 7

Rapid onset of symptoms 
Pain
Swelling
Unable to bear bed clothes
Can affect one single joint in the lower limb e.g 1st metatarsal pharyngeal joint
Fever

Question 8

What are the differential diagnosis for gout

Answer 8

Reactive arthritis
Mono articular presentation of rheumatoid arthritis
Septic arthritis

Question 9

What are the investigations for gout

Answer 9

Blood: FBC, raised ESR/CRP
Renal function and urate
Blood culture: infection
Synovial fluid: polarised light microscopy for crystals

Question 10

What is the management of gout if acute

Answer 10

NSAIDs or Colchicine (first line)
Corticosteroids
Ice

Question 11

What is the chronic treatment for gout

Answer 11

Lifestyle advice: reduce alcohol intake
Colchine or NSAID if not tolerated
Allopurinol

Question 12

What is pseudogout

Answer 12

Microcrystalline synovitis caused by the deposition of calcium pyrophosphate (CPP) dihydrate crystals in the synovium

Question 13

What are the risk factors for pseudogout

Answer 13

Hyperparathyrodisim- hypercalcium
Low magnesium
Low phosphate

Question 14

What is the diagnosis of pseudogout by

Answer 14

Identification of CPP crystals in the synovial fluid joint aspiration
X-ray: chondracalcinosis

Question 15

What is the management of pseudogout

Answer 15

NSAIDs
Colchicine
Steroid

Question 16

What is Spondylarthropathy

Answer 16

A term given to related inflammatory arthropathies that have common features of:
Inflammation of the spine
Sacro iliac involvement
Enthesis (point of attachment of a ligament or tendon to a bone that is inflammed)

Question 17

What conditions are Spondylarthropathy

Answer 17

Ankylosing spondylitis 
Reactive arthritis
Psoriatic arthritis 
Enteropathic spongylathropathy 
Undifferentiated Spondylarthropathy

Question 18

What are the causes of Spondylarthropathy

Answer 18

Genetic factors: HLAB27
Environmental factors
Infective triggers

Question 19

What are the common features of Spondylarthropathy

Answer 19

Sacroiliac and Spinal involvement: chronic pain, back pain, buttock pain
Enthesitis
Peripheral asymmetric arthritis
Dactylitis: this is painful swelling of whole digit
Ocular inflammation: painful, red eye
Skin lesions

Question 20

What does ankylosing spondylitis present as

Answer 20

In young adults

Inflammatory back pain and stiffness

Question 21

What are the features of ankylosing spondylitis

Answer 21

Chronic lower back pain
Pain worse in the morning and wakes someone up
Peripheral synovitis at hips and shoulders
Chest wall pain
Extra articular manifestations; peripheral arthritis, iritis, colitis, pulmonary fibrosis

Question 22

What is the criteria to diagnose ankylosing spondylitis

Answer 22

Inflammatory back pain for more than 3 months with 1 or more of:
Alternate buttock pain
Sacroilitis on x-ray
Positive family history 
IBD 
Psoriasis 
Enthesopathy

Question 23

What are the investigations for ankylosing spondylitis

Answer 23

Bloods: ESR, CRP, usually raised
X-ray: sacroiliac joints
Ultrasound Doppler for enthesitis

Question 24

What is the pharmacological management of as

Answer 24

NSAID

DMARD (methotrexate, anti tnf, corticosteroids, suphasalazine)

Question 25

What is psoriatic arthritis

Answer 25

Chronic inflammatory arthritis found in patients with psoriasis

Question 26

What are the clinical features of pa

Answer 26

Dactylitis (sausage shaped digit)
Current psoriasis
Nail pits
Absence of rheumatoid factor and nodule
Sacroilitis

Question 27

What is the management of pa

Answer 27

NSAIDs
DMARD (methotrexate, leflunomide, ssa)
Anti tnf
Corticosteroids

Question 28

What is reactive arthritis

Answer 28

An inflammatory arthritis that develops after a gut or genitourinary tract infection (2-4 weeks after)

Question 29

What is the presentation of reactive arthritis

Answer 29

Lower limb aligoarthritis 
Lower back pain, buttock pain
Enthesitis 
Systemic features: temperature 
Keratoderma blennorhagica

Question 30

What organism from the GI can cause reactive arthritis

Answer 30

Salmonella
Shigella
Neisseria
Yersinia 
Campylobacter

Question 31

Which organism can cause reactive arthritis from the genitourinary tract

Answer 31

Chalmydia

Question 32

What investigations can be carried out in reactive arthritis

Answer 32

Stool culture: if there is diarrhoea
Urethral swab for STI e.g chlamydia
Routine blood: rheumatoid factor and CRP
Joint aspiration : mono arthritis to rule out septic arthritis
X-ray for sacroiliac joints

Question 33

What is the management of reactive arthritis

Answer 33

NSAID
Intra articular cortisone
Doxycycline for people with chlamydia

Question 34

What is enteropathic arthritis

Answer 34

This is arthritis that present with people with ulcerative colitis of Crohn’s disease (IBD)

Question 35

What does enteropathic arthritis present as

Answer 35

Axial involvement
Sacroiliac involvement
Acute peripheral arthritis: knee, ankles and wrists