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MSK/Derm > SM 235: Crystalline Diseases > Flashcards

SM 235: Crystalline Diseases Flashcards

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1
Q

What characterizes Crystalline Arthropathies?

A

Inflammation in a joint + crystals in Synovial fluid

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2
Q

What will Synovial fluid analysis report in a crystal arthropathy?

A

Inflammatory fluid = slightly turbid + 2,000 - 50,000 WBC’s + 20-70% PMN’s; less than Septic

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3
Q

Can a person have gout and septic arthritis at the same time, and how does this influence treatment?

A

Yes, any time you order Synovial fluid, grow cultures as well to test for pathogens in addition to possible gout-inflammation

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4
Q

What are the 3 types of joint crystals?

A

Basic Calcium Phosphate (BCP), Calcium Pyrophosphate Dihydrate (CPPD), and Monosodium Urate (Gout)

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5
Q

What are BCP crystals also known as?

A

BCP = Basic Calcium Phosphate = Calcium Hydroxyapatite (found normally in bone)

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6
Q

Where do BCP crystals tend to deposit and what diseases do these deposits correlate with?

A

Soft Tissues = Acute Calcific Periarthritis

Joints = BCP Arthropathy

Tendons = Calcific Tendonitis

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7
Q

What is Acute Calcific Periarthritis, what type of crystal does it involve, and give an example?

A

BCP Crystal deposits in soft tissue, such as pseudo-podagra of the 1st MTP in women = intense local inflammation

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8
Q

What is BCP Arthropathy, what type of crystal does it involve, and give an example?

A

BCP Crystal deposits in joints, such as Milwaukee Shoulder Syndrome = large/inflammed shoulder joint

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9
Q

What is Calcific Tendonitis, what type of crystal does it involve, and give an example?

A

BCP Crystal deposits, such as in the supraspinatus tendon of the shoulder leading to Bursitis

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10
Q

What do BCP crystals look like on microscopy?

A

Shiny coins on ordinary light microscopy No bifringent on polarized light microscopy Stains on Alizarin Red

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11
Q

What type of crystal stains on Alizarin Red?

A

BCP crystals

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12
Q

What type of crystal does not show bifringence on polarized light micrsocopy?

A

BCP Crystals

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13
Q

What type of crystal appears like shiny coins on ordinary light micrsocopy?

A

BCP crystals

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14
Q

What is unique about Synovial fluid analysis in BCP crystal mediated arthritis?

A

Unlike Gout and Pseudogout, the Synovial fluid is non-inflammatory (like OA)

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15
Q

How should BCP arthropathy be treated?

A

Symptomatic only: NSAIDS, PT, steroids

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16
Q

What type of crystal causes Pseudogout?

A

CPPD = calcium pyrophosphate dihydrate

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17
Q

What are the major risk factors for CPPD arthritis?

A

Affects elderly women with a predilection for joints previously affected by Osteoarthritis

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18
Q

Which type of crystal is more likely to form in a joint previously effected by OA?

A

CPPD crystals have a tendency to form in joints effected by OA

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19
Q

What could cause CPPD crystals in a younger person?

A

Normally only seen in older people, metabolic disturbances hike Hyper and Hypoparathyroidism, Hypomagneisa, and Hypothyroiodism

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20
Q

How does a patient with CPPD crystals present?

A

Pseudogout presents as acute monoarthritis in the knees or wrist OR RA mimic as symmetric in small joints OR Progressive Osteoarthritis of large, small joints OR Asymptomatic chondrocalcinosis

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21
Q

Does Chondrocalcinosis = CPPD?

A

No; 30% of the population has Chondrocalcinosis on Xrays by 90 y/o

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22
Q

Where does Chondrocalcinosis tend to occur and what does it look like on Xray?

A

Tends to occur in knee joint and wrist, and apepars as white deposits in the joint space

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23
Q

What do CPPD crystals look like under microscopy?

A

Appear pleomorphic and weakly birefringent on polarized light microscopy

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24
Q

How do the shapes of CPPD and Gout crystals compare?

A

CPPD is rhomboid shaped whereas Gout is needle shaped

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25
Q

What is the treatment for CPPD?

A

NSAIDS, steroids, and Colchicine

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26
Q

What are the prophylactic agents for CPPD?

A

There aren’t any, only treat acute attacks

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27
Q

What serum marker is Gout associated with?

A

Serum uric acid; rises in uric acid = higher risk of gout

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28
Q

When does gout develop in men and women?

A

Women = perimenopausal and men = onset of puberty

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29
Q

Which sex is affected by Gout more?

A

Males, though it evens out postmenopause

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30
Q

Why do women develop Gout after menopause?

A

Estrogen protects against uric acid buildup, which drops off after Menopause

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31
Q

Why is alcohol consumption a risk factor for Gout?

A

Alcohol increases ATP degradation = increases urate synthesis, and an increase in lactic acid = decreased urate excretion

32
Q

Why does drinking beer predispose Gout?

A

Beer has a high purine content that degrades into Urate

33
Q

What are the risk factors for gout?

A

Alcohol consumption, obesity, metabolic syndrome, insulin resistance

34
Q

What are dietary risk factors for gout?

A

Anything rich in purines: meat, shellfish, ehtanol, and soft drinks

35
Q

What drugs predispose gout?

A

Thiazides, cyclosporine, and low dose aspirin raise uric acid levels

36
Q

Why does renal insufficiency increase risk of gout?

A

Decreases uric acid clearance

37
Q

What can cause Hyperuricemia, and how does it lead to gout?

A

Hyperuricemia leads to gout by raising uric acid levels May be due to overproduction of uric acid or underexcretion

38
Q

What can cause overproduction of uric acid?

A

Enzyme abnormalities in the Purine degradation pathway, hemolytic disease, cancer and alcohol

39
Q

What can cause underexcretion of uric acid?

A

Decreased renal function, diuretics/cyclosporine/aspirin, alcohol

40
Q

Why is alcohol such a big risk factor for gout?

A

Alcohol increases production of uric acid and decreases excretion of uric acid, drastically raising the risk of hyperuricemia

41
Q

What are the stages of Gout?

A

Asymptomatic hyperuricemia Acute gout arthritis Intercritical gout Chronic tophaceous gout

42
Q

What is asymptomatic hyperuricemia?

A

Uric acid levels rising without symptoms of gout, up to a uric acid level of 7

43
Q

What is acute gout arthritis?

A

Gout in a single joint

44
Q

What is intercritical gout?

A

A secondary gout attack within 2 years of a short recovery period after the first one

45
Q

What is chronic tophaceous gout?

A

Uncontrolled frequent gout attacks that presents with white nodules on the ears, digits, and olecranon

46
Q

How does gout present?

A

Acute monoarthritis usually involving the first MTP = podagra, though any joing can be effected

47
Q

How painful is gout and when does the pain begin?

A

Extremely painful, patients cant tolerate bedsheets touchign the affected joint, pain begins very early morning

48
Q

How does the pain of gout differ from rheumatic and osteoarthritis?

A

Gout pain is severe and acute, OA and RA are less intense and more insidouos

49
Q

How do the gout attacks resolve?

A

First few gout attacks resolve on their own without specific therapy after a week, but over time the attacks become longer and more resistant to therapy

50
Q

Can gout be chronic?

A

Yes, if hyperuricemia is untreated, gout can become chronic and polyarticular after longstanding disease

51
Q

How is gout diagnosed?

A

Find needle-shaped crystals on microscopy from synovial fluid analysis

52
Q

Describe the color of gout crystals?

A

Needle shaped gout crystals are yellow when they’re parallel to the light polarizer; blue crystals when perpendicular

53
Q

How is gout treated?

A

Allopurinol to neutralize the uric acid

54
Q

What can be seen on radiography for gout?

A

Large erosions in random joints, punched out lesions, and sclerotic overhanging edges

55
Q

Does gout preserve joint spaces?

A

Surprisingly, yes, until the disease is very advanced

56
Q

What are the treatement goals for gout?

A

Provide rapid and safe pain relief, prevent further attacks, and prevent formatino of tophi/destructive arthritis

57
Q

How should an acute gout attack be treated?

A

NSAIDS, Colchicine, and corticosteroids

58
Q

What should be done if a patient on a chronic urate lower therapy like Allopurinol has an acute gout attack?

A

Don’t stop the urate lowering drug, just keep taking it at the normal dose

59
Q

When should someone have chronic gout therapy?

A

Recurrent attacks in the same year, renal stones, tophaceous gout (thick deposits on skin) and erosive changes on Xray

60
Q

What are the drug classes used to treat gout?

A

Xanthine Oxidase inhibitors and Uricosuric Agents

61
Q

What are Xanthine Oxidase inhibitors?

A

Decrease production of urate: Allopurinol and Febuxostat

62
Q

What are Uricosuric Agents?

A

Increase excretion of urate: Probenecid and lesinurad

63
Q

Why should you be caution when starting chronic gout therapy?

A

Changing gout levels in blood can actually precipitate a gout attack

64
Q

Can you use a chronic gout therapy for an acute gout attack?

A

Nope, always give a patient some form of gout prophylaxis like NSAIDS or colchicine to take during acute attacks

65
Q

What is the absolute last resort drug for treating gout?

A

Pegloticase; an IV administration of Uricase, an enzyme that degrades Urate but may trigger a hypersensitivity reaction so only give it for treatment resistant gout

66
Q

What type of crystal is this?

A

Monosodium Urate - Gout Crystals

67
Q

What is this?

A

Acute Calcific Periarthritis

68
Q

What is this and what kind of crystal causes it?

A

Milwaukee Shoulder - BCP Arthropathy

69
Q

What type of crystal is this?

A

CPPD crystals from Pseudogout because of it’s Rhomboid shape

70
Q

What is this?

A

Chondrocalcinosis

71
Q

What are these crystals?

A

CPPD on the left and Monosodium Urate on the right

72
Q

What are these crystals and why?

A

CPPD crystals from Pseudogout due to rhomboid shape

73
Q

What crystal is causing this and what disease is it?

A

Monosodium Urate from Gout depositing in the Big Toe, a classic finding

74
Q

What are these and what do they suggest?

A

Monosodium Urate deposition in the fingers and ears suggests Chronic Tophaceous Gout

75
Q

What disease is this and why?

A

Gout - bifringescne on polarized light and needle shaped crystals

76
Q

What crystalline disease does this Xray suggest?

A

Suggests gout due to perseved joint spaces and punched out lesions, as well as sclerotic overhang

MSK/Derm (46 decks)

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