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MSK/Derm > SM 235: Crystalline Diseases > Flashcards

SM 235: Crystalline Diseases Flashcards

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
What is the treatment for CPPD?
NSAIDS, steroids, and Colchicine
26
What are the prophylactic agents for CPPD?
There aren't any, only treat acute attacks
27
What serum marker is Gout associated with?
Serum uric acid; rises in uric acid = higher risk of gout
28
When does gout develop in men and women?
Women = perimenopausal and men = onset of puberty
29
Which sex is affected by Gout more?
Males, though it evens out postmenopause
30
Why do women develop Gout after menopause?
Estrogen protects against uric acid buildup, which drops off after Menopause
31
Why is alcohol consumption a risk factor for Gout?
Alcohol increases ATP degradation = increases urate synthesis, and an increase in lactic acid = decreased urate excretion
32
Why does drinking beer predispose Gout?
Beer has a high purine content that degrades into Urate
33
What are the risk factors for gout?
Alcohol consumption, obesity, metabolic syndrome, insulin resistance
34
What are dietary risk factors for gout?
Anything rich in purines: meat, shellfish, ehtanol, and soft drinks
35
What drugs predispose gout?
Thiazides, cyclosporine, and low dose aspirin raise uric acid levels
36
Why does renal insufficiency increase risk of gout?
Decreases uric acid clearance
37
What can cause Hyperuricemia, and how does it lead to gout?
Hyperuricemia leads to gout by raising uric acid levels May be due to overproduction of uric acid or underexcretion
38
What can cause overproduction of uric acid?
Enzyme abnormalities in the Purine degradation pathway, hemolytic disease, cancer and alcohol
39
What can cause underexcretion of uric acid?
Decreased renal function, diuretics/cyclosporine/aspirin, alcohol
40
Why is alcohol such a big risk factor for gout?
Alcohol increases production of uric acid and decreases excretion of uric acid, drastically raising the risk of hyperuricemia
41
What are the stages of Gout?
Asymptomatic hyperuricemia Acute gout arthritis Intercritical gout Chronic tophaceous gout
42
What is asymptomatic hyperuricemia?
Uric acid levels rising without symptoms of gout, up to a uric acid level of 7
43
What is acute gout arthritis?
Gout in a single joint
44
What is intercritical gout?
A secondary gout attack within 2 years of a short recovery period after the first one
45
What is chronic tophaceous gout?
Uncontrolled frequent gout attacks that presents with white nodules on the ears, digits, and olecranon
46
How does gout present?
Acute monoarthritis usually involving the first MTP = podagra, though any joing can be effected
47
How painful is gout and when does the pain begin?
Extremely painful, patients cant tolerate bedsheets touchign the affected joint, pain begins very early morning
48
How does the pain of gout differ from rheumatic and osteoarthritis?
Gout pain is severe and acute, OA and RA are less intense and more insidouos
49
How do the gout attacks resolve?
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
Can gout be chronic?
Yes, if hyperuricemia is untreated, gout can become chronic and polyarticular after longstanding disease
51
How is gout diagnosed?
Find needle-shaped crystals on microscopy from synovial fluid analysis
52
Describe the color of gout crystals?
Needle shaped gout crystals are yellow when they're parallel to the light polarizer; blue crystals when perpendicular
53
How is gout treated?
Allopurinol to neutralize the uric acid
54
What can be seen on radiography for gout?
Large erosions in random joints, punched out lesions, and sclerotic overhanging edges
55
Does gout preserve joint spaces?
Surprisingly, yes, until the disease is very advanced
56
What are the treatement goals for gout?
Provide rapid and safe pain relief, prevent further attacks, and prevent formatino of tophi/destructive arthritis
57
How should an acute gout attack be treated?
NSAIDS, Colchicine, and corticosteroids
58
What should be done if a patient on a chronic urate lower therapy like Allopurinol has an acute gout attack?
Don't stop the urate lowering drug, just keep taking it at the normal dose
59
When should someone have chronic gout therapy?
Recurrent attacks in the same year, renal stones, tophaceous gout (thick deposits on skin) and erosive changes on Xray
60
What are the drug classes used to treat gout?
Xanthine Oxidase inhibitors and Uricosuric Agents
61
What are Xanthine Oxidase inhibitors?
Decrease production of urate: Allopurinol and Febuxostat
62
What are Uricosuric Agents?
Increase excretion of urate: Probenecid and lesinurad
63
Why should you be caution when starting chronic gout therapy?
Changing gout levels in blood can actually precipitate a gout attack
64
Can you use a chronic gout therapy for an acute gout attack?
Nope, always give a patient some form of gout prophylaxis like NSAIDS or colchicine to take during acute attacks
65
What is the absolute last resort drug for treating gout?
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
What type of crystal is this?
Monosodium Urate - Gout Crystals
67
What is this?
Acute Calcific Periarthritis
68
What is this and what kind of crystal causes it?
Milwaukee Shoulder - BCP Arthropathy
69
What type of crystal is this?
CPPD crystals from Pseudogout because of it's Rhomboid shape
70
What is this?
Chondrocalcinosis
71
What are these crystals?
CPPD on the left and Monosodium Urate on the right
72
What are these crystals and why?
CPPD crystals from Pseudogout due to rhomboid shape
73
What crystal is causing this and what disease is it?
Monosodium Urate from Gout depositing in the Big Toe, a classic finding
74
What are these and what do they suggest?
Monosodium Urate deposition in the fingers and ears suggests Chronic Tophaceous Gout
75
What disease is this and why?
Gout - bifringescne on polarized light and needle shaped crystals
76
What crystalline disease does this Xray suggest?
Suggests gout due to perseved joint spaces and punched out lesions, as well as sclerotic overhang

MSK/Derm (46 decks)

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