Monoarticular Joint Pain :Crystal arthritis Flashcards
What kind of crystals are deposited in gout?
monosodium urate (uric acid)
What kind of crystals are deposited in pseudogout?
calcium pyrophosphate
What are the characteristics of crystal arthritis?
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
Pathogenetic process of gout?
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
What causes hyperuricemia?
Overproduction: Excess dietary purines, Alcohol abuse, Myeloproliferative disorder, Lymphoproliferative disorder.
Under excretion: Renal disease, Polycystic kidney disease
Drugs causing Hyperuricemia
CANT LEAP:
Cyclosporine
Alcohol
Nicotinic acid
Thiazides
Lasix (Frusemide)
Ethambutol
Aspirin (low dose)
Pyrazinamide
When is gout most common?
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
What are the 4 stages of gout?
Asymptomatic hyperuricemia
A/C gouty attacks
Intercritical gout
Advanced tophaceous gout
What are some predisposing factors of gout?
Immediate postop period after major surgery
a/c MI
Stroke
Fasting
Alcohol abuse
Large intake of food with high purine content
Local infection
Where is the most common place for the first gout attack?
70% first attack - mtp joint of great toe
What happens in the lab when you asperate the fluid?
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)
What characteristics are seen in radiography gout imaging?
Well defined erosions
Sclerotic borders
Overhanging edges
No osteoporosis
What are some core management schemes for a person w/gout?
Patient Education
Diet- low purine
Reduce alcohol
Weight reduction
Why can alcohol intake increase risk of gout attack?
Alcohol increase serum urate production and reduce renal clearance.
What are some things done w/ regard to diet done for gout?
GENERAL THINGS TO DIET
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
what management is done specifically for an acute attack?
Joint rest &local ice
NSAIDS or COX II
Oral Steroids.
Local steroid injection.
Oral colchicine
what management is done specifically for an Intercritical gout?
Diet
Alcohol
Colchicine prophylaxis
Urate lowering drugs
—-Allopurinol
- —-Uricosuric drugs
2 or more attacks in a year
when is Colchicine prophylaxis given?
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.
what is Long term management of gout?
Offer ULT, using a treat-to-target strategy,
multiple or troublesome flares
CKD stages 3 to 5
diuretic therapy
tophi
chronic gouty arthritis.
When is pseudogout most common?
8% of over 60s, 30% over 90
most common in older women
Conditions predisposing for pseudogout?
Ageing
Hyperparathyroidism
Hemochromatosis
Hypomagnesemia
Hypophosphatasia
May follow parathyroidectomy
Acromegaly
Hypothyroidism
Trauma
Infection
Osteoarthritis
Radiographic Appearance for pseudogout?
Calcium deposition triangular fibrocartilage
Subchondral sclerosis,
Joint space narrowing,
Subchondral cyst formations
most common at the radiocarpal articulation
2nd and 3rd MCP.
Treatment of psuedogout?
Acute attack-joint aspiration & steroid injection.
Antiinflammatories.
Chronic pseudogout
Anti infl & periodic intraarticular steroid injn
Associated disease managed.
