Week 2 Crystal induced arthopathies Flashcards
List the crystal species and their associated arthritic disorders.
- Monosodium urate- Gout
- Calcium pyrophosphate - Pseudogout
- Hydroxy apatite - Calcific periarthritis
Describe the inflammation response to crystals.
- stimulate release of inflammatory mediators: arachidonic acid, Il-1,6,8, TNF
- granulocyte influx promoted
What are the clinical features of gout?
-arthritis
-tophi
-kidney stones
-nephropathy
Presentation
-intermittent attacks, initial symptoms peak at 12 hours, first MTP (big toe) joint affect frequently initially. Inflammation and marked pain.
-sodium urate crystals initiate the acute attack, need shaped and show negative birefringence
-attack will last a few days or weeks and subside
-systemic symptoms, fever and chills
-recurrent attacks
-tophaceous deposits over time
Who does gout affect?
- 8.4/1000 ppl
- those with renal impairment
- lipoprotein abnormalities
- increasing body mass
- excessive alcohol consumption
- familial gout 20%
Describe tophaceous gout (chronic gout).
- generally 10 years+ of gout
- no longer pain free between attacks
- subQ deposits of urate accumulate, without treatment 50% will develop tophi
- may occur in abnormal places: spine and CNS
What are radiographic features of gout?
- x rays generally normal early on
- soft tissue swelling during acute attacks
- gouty destruction of bone characteristics: erosions slightly removed from joint surface, atrophic and hypertrophic features result in overhanging edge appearance
How is acute gout treated? How is hyperuricemia treated?
- Colchicine-effect in early attacks and to prevent attacks during asymptomatic intervals
- NSAIDS
Hyperuricemia - Uricosuric drugs: contraindicated in patients with over excretion of uric acid
- Allopurinol-inhibits xanthine oxidase
- diet
What is calcium pyrophosphate dehydrate crystal deposition disease (CPPD)?
- pseudogout
- gout like attacks
- may mimic other conditions such as RA and septic arthritis
- crystal accumulate in cartilage
- chondrocalcinosis on x ray
Describe the clinical features of pseudo gout.
- acute attacks 3-14 days
- self limited but respond to treatment
- predilection for larger joint involvement compared to real gout
- first attack knee joint 50%
- nearly all joints can be affected
- asymptomatic between attacks
- low grade fever common with acute attacks
- chronic symptoms in some patients: OA of knees, pseudo rheumatoid polyarthritis
What are CPPD disease associations (associations with chondrocalcinosis)?
- Hyperparathyroidism ! most notable
- hemochromatosis
- hypothyroidism
- hypomagnesemia
- hypophosphatasic
- amyloidosis
What are radiographic features of CPPD?
- calcifications visible on plain films
- generally linear calcific densities in cartilage
- may occur in joint capsule, ligaments, tendons, isolated patellofemoral arthritis, or wrist degeneration
- If see medial or lateral meniscus deposition of calcification if patellafemoral
How is CPPD treated?
- No practical way to remove CPPD crystals from cartilage
- Treatment of associated conditions does not remove crystals
- Local treatment of acute affected joints with aspiration and steroid injection helpful
- oral ant inflammatory medications and/or colchicine generally effective
Describe basic calcium phosphate crystal deposition disease.
-acute and chronic calcific periarthritis
-large joint destruction arthritis
-calcinosis cutis
-may cause local inflammation
-generally more periarticular symptoms
-crystals: apatites, tricalcium phosphate, octacalcium phosphate
Diagnosis:
-tendonitis
-softe tissue calcifications on x ray
-crystals can’t be confirmed with polarizing microscope
-coin like clumps may be seen with light microscope
Treatment
-NSAIDs, local injection with corticosteroid, physical therapy
What conditions are associated with urate overproduction?
- HGRFT deficiency: in the purine salvage pathway
- PRPP synthetase superactivity: in the de novo purine synthesis
- myeloproliferative disease
- hemolysis
- psoriasis
- glycogen storage disease
- ethanol
