Monoarticular Joint Pain :Crystal arthritis

Question 1

What kind of crystals are deposited in gout?

Answer 1

monosodium urate (uric acid)

Question 2

What kind of crystals are deposited in pseudogout?

Answer 2

calcium pyrophosphate

Question 3

What are the characteristics of crystal arthritis?

Answer 3

High Viscosity in the normal knee, but low Viscosity in the affected knee.
clear colour in the normal knee but synovial fluid in the affected knee is straw/opaque
WBC in normal knee: 200 but in arthritic is more than 10,000

Question 4

Pathogenetic process of gout?

Answer 4

Overproduction of uric acid (exogenous or endogenous)
Underexcretion of uric acid (abnormal renal handling of urate)
A combination of both
uric acid gets deposited in the joint

Question 5

What causes hyperuricemia?

Answer 5

Overproduction: Excess dietary purines, Alcohol abuse, Myeloproliferative disorder, Lymphoproliferative disorder.
Under excretion: Renal disease, Polycystic kidney disease

Question 6

Drugs causing Hyperuricemia

Answer 6

CANT LEAP:
Cyclosporine
Alcohol
Nicotinic acid
Thiazides
Lasix (Frusemide)
Ethambutol
Aspirin (low dose)
Pyrazinamide

Question 7

When is gout most common?

Answer 7

Most common infl arthritis in men over 40.
After menopause increase in women-loss of uricosuric effect of oestrogen.
Attacks of gout more severe and difficult to treat.
Aging population
Comorbidities eg: renal failure contradicting many therapeutic options

Question 8

What are the 4 stages of gout?

Answer 8

Asymptomatic hyperuricemia
A/C gouty attacks
Intercritical gout
Advanced tophaceous gout

Question 9

What are some predisposing factors of gout?

Answer 9

Immediate postop period after major surgery
a/c MI
Stroke
Fasting
Alcohol abuse
Large intake of food with high purine content
Local infection

Question 10

Where is the most common place for the first gout attack?

Answer 10

70% first attack - mtp joint of great toe

Question 11

What happens in the lab when you asperate the fluid?

Answer 11

Joint fluid analysis
WCC in joint fluid (5,000-50,000/mm3) neutrophils.
Culture to r/o infection
S. uric acid & WCC <15,000/mm3
Renal function.
Urine dipstick – haematuria (gout and kidney stone)

Question 12

What characteristics are seen in radiography gout imaging?

Answer 12

Well defined erosions
Sclerotic borders
Overhanging edges
No osteoporosis

Question 13

What are some core management schemes for a person w/gout?

Answer 13

Patient Education
Diet- low purine
Reduce alcohol
Weight reduction

Question 14

Why can alcohol intake increase risk of gout attack?

Answer 14

Alcohol increase serum urate production and reduce renal clearance.

Question 15

What are some things done w/ regard to diet done for gout?
GENERAL THINGS TO DIET

Answer 15

Food high in purines include:
Red meat
Animal organs- liver, kidney, brain
Fish - mackerel, herring, sardines, codfish, trout, haddock, and anchovies
shellfish - scallops and mussels

Question 16

what management is done specifically for an acute attack?

Answer 16

Joint rest &local ice
NSAIDS or COX II
Oral Steroids.
Local steroid injection.
Oral colchicine

Question 17

what management is done specifically for an Intercritical gout?

Answer 17

Diet
Alcohol
Colchicine prophylaxis
Urate lowering drugs
—-Allopurinol
- —-Uricosuric drugs
2 or more attacks in a year

Question 18

when is Colchicine prophylaxis given?

Answer 18

Colchicine prophylaxis for the 1st 3-6 months to reduce the frequency of attacks.
s/e-rash, hepatotoxicity severe hypersensitivity.
Compliance poor. Gout worsen early in therapy. Not stop allopurinol if an a/c attack develops.

Question 19

what is Long term management of gout?

Answer 19

Offer ULT, using a treat-to-target strategy,
multiple or troublesome flares
CKD stages 3 to 5
diuretic therapy
tophi
chronic gouty arthritis.

Question 20

When is pseudogout most common?

Answer 20

8% of over 60s, 30% over 90
most common in older women

Question 21

Conditions predisposing for pseudogout?

Answer 21

Ageing
Hyperparathyroidism
Hemochromatosis
Hypomagnesemia
Hypophosphatasia
May follow parathyroidectomy
Acromegaly
Hypothyroidism

Trauma
Infection
Osteoarthritis

Question 22

Radiographic Appearance for pseudogout?

Answer 22

Calcium deposition triangular fibrocartilage
Subchondral sclerosis,
Joint space narrowing,
Subchondral cyst formations
most common at the radiocarpal articulation

2nd and 3rd  MCP.

Question 23

Treatment of psuedogout?

Answer 23

Acute attack-joint aspiration & steroid injection.

Antiinflammatories.

Chronic pseudogout

Anti infl & periodic intraarticular steroid injn

Associated disease managed.