PMR And Crystals

Question 1

What are the different crystal deposition diseases and their presentations?

Answer 1

Gout - monosodium urate deposition
Presents with sudden onset of severe pain, swelling, warmth and redness of a joint, commonly base of big toe

Pseudogout - calcium pyrophosphate dihydrate
Presents with similar findings as gout, typically occurring in the knee

Calcific periarthritis/tendonitis - basic calcium phosphate hydroxy-apatite
Presents with similar symptoms as above, however swelling is around not in the joint, commonly affecting shoulders

Question 2

Why may hyperuricaemia occur?

Answer 2

In the vast majority it occurs due to reduced efficiency of renal urate clearance.

However overproduction of urate can be caused by: malignancy, severe exfoliative psoriasis, drugs, inborn errors of metabolism, HGPRT deficiency.

Under excretion can be due to: renal impairment, hypertension, hypothyroidism, drugs, exercise, starvation, dehydration, lead poisoning

Question 3

How would you manage an acute attack of gout?

Answer 3

NSAIDs
Colchicine
Steroids (intra-articular, IM, oral)

Question 4

How do you manage hyperuricaemia?

Answer 4

First is it needed to be treated?
First attack = NO
Unless: polyarticular, tophaceous gout, urate calculi, renal insufficency

2nd attack <1yr = YES

Prophylaxis prior to treating certain malignancies
Do not treat if asymptomatic

Wait until acute attack has settled. Use prophylactic NSAIDS or other until level of urate is normal. Adjust allopurinol according to renal function. Address CV and lifestyle factors.
Via: xanthine oxidase inhibitor eg allopurinol, febuxostat, uricosuric agents, canakinumab.

Question 5

What are the symptoms and signs of polymyalgia rheumatica?

Answer 5

SUDDEN ONSET Muscle stiffness >45min in the morning. Typically shoulder +/- pelvic girdle. Others include: extreme tiredness, appetite loss, weight loss, depression, signs of anaemia
Typically elderly, inflammatory condition of the muscles around shoulders, neck, hips and thighs.

Question 6

What is the association between polymyalgia rheumatic and giant cell arthritis?

Answer 6

20% patients with PMR may have evidence of GCA. GCA leads to high ESR, anaemia, leads to PMR, leads to GCA and so on.

Question 7

How do you manage polymyalgia rheumatica?

Answer 7

Prednisolone 15mg/d initially, 18-24m course and bone prophylaxis