Rheumatology

Question 1

Name the different types of gout?

Answer 1

Gout
Pseudogout

Question 2

What is the pathophysiology of pseudogout?

Answer 2

Microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate crystals in the synovium.

For this reason, it is now more correctly termed acute calcium pyrophosphate crystal deposition disease.

Question 3

Risk factors for developing pseudogout?

Answer 3

age
haemochromatosis
hyperparathyroidism
low magnesium, low phosphate
acromegaly
Wilson’s disease

Question 4

Which joint is most commonly affected in pseudogout?

Answer 4

Knee joint

Question 5

What are the symptoms of pseudogout?

Answer 5

knee, wrist and shoulders most commonly affected
pain and swelling - however also often appears asymptomatically

Question 6

What investigations should you arrange to diagnose pseudo-gout?

Answer 6

X-ray - will show deposits of calcium pyrophosphate dihydrate crystals

Aspirate - negative birefringent rhomboid shaped crystals

Question 7

What is the management of an acute flare of pseudogout?

Answer 7

RICE - rest, ICE, compression, elevate

Can use NSAID’s - advise regular ibuprofen/paracetamol, or naproxen with PPI cover if needed

If ongoing and painful - can consider corticosteroid injections

Question 8

What are some differentials for monoarthropathy?

Answer 8

Brusitis
tenosynovitis
cellulitis
gout
OA
Psoriatic arthritis
Reactive arthritis
Septic arthritis
trauma

Question 9

what is the pathophysiology of gout?

Answer 9

Monosodium urate crystal formation and deposition in the synovium, due to either hyperuricaemia or urate under excretion by the kidneys.

Question 10

which joint is typically affected in gout?

Answer 10

first metatarosphalangeal (MTP) joint

Question 11

how does gout present?

Answer 11

red, hot swollen joints
usually monoarthopathy
affects big toe, ankle, wrists and knees commonly
acute presentation - develops mximal intensity of pain within 12 hours

Question 12

what investigations should be carried out for suspected gout?

Answer 12

blood test - uric acid levels (>360 - suspecting of gout)
XR - joint effusion, well defined punched out erosions with sclerotic margins

can also aspirate the synovial fluid - negatively birefringent monosodium urate crystals under polarised light

Question 13

how should the levels or uric acid be interpreted during an acute flare of gout?

Answer 13

a uric acid level ≥ 360 umol/L is seen as supporting a diagnosis
if uric acid level < 360 umol/L during a flare and gout is strongly suspected, repeat the uric acid level measurement at least 2 weeks after the flare has settled

Question 14

how should an acute flare of gout be managed?

Answer 14

RICE

Can offer one of the following:
- NSAID at maximum dose (i.e. naproxen) - to be taken for 1-2 days after acute attack resolved. Consider PPI cover.
- Colchicine
- short course of oral corticosteroid such as prednisolone for 3-5 days.

Second line -
- corticosteroid injection

advise to CONTINUE preventative ULT during acute gout attack.

Question 15

how should chronic gout be managed?

Answer 15

lifestyle advice
start urate lowering therapy

Question 16

who should have chronic management of gout?

Answer 16

Multiple or troublesome flares.
Chronic kidney disease (CKD) stages 3 to 5 (glomerular filtration rate [GFR] categories G3 to G5).
Diuretic therapy.
Tophi.
Chronic gouty arthritis.

Question 17

what lifestyle advice should be given for gout?

Answer 17

To follow a healthy, balanced diet, and explain that there is not enough evidence to show that any specific diet prevents flares or lowers serum urate levels.

That excess body weight, obesity or excessive alcohol consumption may exacerbate gout flares and symptoms.

Question 18

what medications can be used to manage chronic gout?

Answer 18

Offer allopurinol, or febuxostat first-line taking into account the person’s preferences and comorbidities.

Offer allopurinol first-line to people with gout who have major cardiovascular disease (for example, myocardial infarction, stroke, or unstable angina).

Question 19

how does PMR present?

Answer 19

pain and stiffness that is worst in the morning, and particularly affects the shoulders and hips

Question 20

what is the criteria for diagnosis of PMR?

Answer 20

bilateral shoulder and/or pelvic girdle ache
morning stiffness > 45 mins
abrupt onset
age over 50 years
duration more than 2 weeks
evidence of an acute phase response (i.e. increased ESR/CRP)

Question 21

who is PMR most common in?

Answer 21

patients over 50 years old
more common in women
common in caucasians
association with HLA-DR4

Question 22

what investigations should be carried out in PMR?

Answer 22

ESR
CRP
FBC
RF negative
LFT, U+E
Myeloma screen
TSH
bone prof
chest XR if prominent chest symptoms
ANA
usually should be done before commencing steroids