6b(ii) Gout and pseudogout

D Non-steroidal anti inflammatory agents

A 57-year-old male recently on a high protein diet presents with an exquisitely tender, erythematous, warm right great toe. Which of the following is the treatment of choice for this patient? A Corticosteroids B colchicine C Allopurinol D Non-steroidal anti inflammatory agents

gout

A pathology report comes back showing negatively birefringent crystals. What is the most likely diagnosis?

Pseudogout

A pathology report comes back with positive birefringent crystals. What is the most likely diagnosis?

Gout(pearls) Gout involves the accumulation of uric acid in soft tissue of joints and bone Attacks are secondary to purine-rich foods (alcohol, liver, oily fish, yeasts) causing rapid changes in uric acid concentration. - Medications: diuretics (thiazides and loop), ACEI, ethambutol, aspirin, ARB's most common in men > 30 years old and postmenopausal women. Clinical manifestations of gout 1 Acute Gouty Arthritis: 80% monoarthropathy with joint erythema, swelling, and stiffness (often extends past the joint). The great toe is often first affected. 2 Tophi deposition: collection of solid uric acid in soft tissue (helix of ear, eyelids, and Achilles tendon) 3 Uric acid nephrolithiasis and nephropathy: uric acid stones associated with low urine volume and acidic PH

Gout (pearls) Gout involves the accumulation of __________ in __________of joints and bone Attacks are secondary to __________-rich foods (alcohol, liver, oily fish, yeasts) causing rapid changes in uric acid concentration. - Medications: diuretics (thiazides and loop), ACEI, ethambutol, aspirin, ARB's most common in (men or women?) > __________years old and __________ women. Clinical manifestations of gout 1 Acute Gouty Arthritis: 80% __________with joint erythema, swelling, and stiffness (often extends past the joint). The __________ is often first affected. 2 Tophi deposition: collection of solid uric acid in __________ (helix of ear, eyelids, and Achilles tendon) 3 Uric acid __________and __________: uric acid stones associated with low urine volume and acidic PH

Gout and pseudogout diagnosis Diagnosis is by arthrocentesis and evaluation of the joint fluid Gout 1 Arthrocentesis shows: negatively birefringent needle-shaped urate crystals 2 X rays: "mouse/rat bite" "punched-out" erosions 3 Increased serum uric acid, increased ESR and WBC during acute attacks Pseudogout = "P"ositively birefringent 1 Arthrocentesis shows: positively birefringent, rhomboid-shaped CPP crystals 2 chondrocalcinosis - linear radiodensities seen on x-ray

Gout and pseudogout diagnosis Diagnosis is by __________and evaluation of the__________ Gout 1 Arthrocentesis shows: __________needle-shaped urate crystals 2 X rays: "__________" "__________" erosions 3 Increased serum __________, increased ESR and WBC during acute attacks Pseudogout = __________birefringent 1 Arthrocentesis shows: __________, rhomboid-shaped CPP crystals 2 __________- linear radiodensities seen on x-ray

D rhomboidal crystals with weak positive birefringence and a normal serum uric acid level The condition described is undoubtedly pseudogout, also known as calcium pyrophosphate deposition disease (CPDD). The symptoms are caused by calcium pyrophosphate deposition in nonosseous tissues in joints, most commonly in a knee. The differential diagnosis includes the many things that can cause swelling and pain in a knee. Considering the patient's age and history, the more likely conditions are osteoarthritis, gout, and pseudogout. The fact that the pain does not become worse during the day points away from but certainly does not exclude osteoarthritis. Similarly, the presence of the condition in the knee rather than in an MTP joint points away from but does not exclude gout. The chondrocalcinosis found on radiographic examination is almost pathognomonic for CPDD, and the presence of rhomboidal crystals with weak positive birefringence in the synovial fluid confirms this diagnosis. The serum uric acid level is not elevated

In the clinical scenario in the patient presentation above which of the following possible results from these laboratory studies is most consistent with the symptoms described and will confirm a diagnosis? A needle-like crystals with negative birefringence and a normal serum uric acid level B needle-like crystals with negative birefringence and a high serum uric acid level C rhomboidal crystals with weak positive birefringence and a high serum uric acid level D rhomboidal crystals with weak positive birefringence and a normal serum uric acid level

Pseudogout

It's the DX? Patient will present as → a 65-year-old man with pain in his right knee. He says he fell and "banged it up fairly bad" approximately 6 months ago but that it had since recovered spontaneously and provided no further trouble until now. He further said the pain does not get worse during the day, and if anything, it hurts more on awakening. His past history showed no hypertension, and he never had any other joint pain of significance. On examination, his temperature is 37.5 °C and his blood pressure is 125/70 mm Hg. He has an inflamed, tender, swollen right knee. No other joints are affected. No other abnormalities are found on physical examination. A plain radiographic examination of the right knee reveals streaking of the surrounding soft tissue with calcium deposits (chondrocalcinosis). You remove accumulated synovial fluid for polarized light microscopic analysis and also obtain a serum sample

Pseudogout (pearls) accumulation of crystals of calcium pyrophosphate dihydrate (CPPD) in the connective tissues. 1 Inflammatory joint pain (knee most common), often associated with hyperparathyroidism.. 2 chondrocalcinosis - linear radiodensities seen on x-ray

Pseudogout (pearls) accumulation of crystals of __________ in the connective tissues. 1 Inflammatory joint pain (__________most common), often associated with __________. 2 chondrocalcinosis - linear __________ seen on x-ray

Treatment GOUT: Acute management: - NSAIDS drug of choice - Indomethacin, Naprosyn (NO ASPIRIN = increased serum uric acid) - Colchicine is 2nd line treatment - Steroids (prednisone) reserved if no response to NSAIDs or colchicine (may be preferable first line therapy in elderly patients) Chronic management: - Allopurinol: reduces uric acid production by inhibiting xanthine oxidase - take with meals to prevent gastric irritation - Uricosuric drugs: probenecid (promotes renal uric acid secretion) -- When given prophylactically add either NSAID or -Colchicine for 3-6 months to prevent acute attack. This can then be discontinued and patient can remain on Allopurinol or uricosuric agent indefinitely. PSEUDOGOUT: Corticosteroids are 1st line, NSAIDs, Colchicine (prophylaxis)

Treatment GOUT: Acute management: - __________drug of choice - Indomethacin, Naprosyn (NO ASPIRIN = increased serum uric acid) - __________ is 2nd line treatment - __________ reserved if no response to NSAIDs or colchicine (may be preferable first line therapy in elderly patients) Chronic management: - __________: reduces uric acid production by inhibiting xanthine oxidase - take with meals to prevent gastric irritation - __________drugs: __________(promotes renal uric acid secretion) -- When given prophylactically add either When given prophylactically add either __________or __________ for 3-6 months to prevent acute attack. This can then be discontinued and patient can remain on Allopurinol or uricosuric agent __________. PSEUDOGOUT: __________are 1st line, NSAIDs, Colchicine (prophylaxis)

D a synovial fluid analysis A definitive diagnosis of gout is made by demonstrating negatively birefringent, needle-shaped monosodium urate crystals under a polarizing microscope. Although an elevated serum uric acid concentration is often seen in acute gout, it is neither as sensitive nor as specific a test as the demonstration of uric acid crystals in synovial fluid under a microscope. Serum uric acid levels can be normal in patients with acute gouty arthritis. The diagnosis of septic arthritis can be ruled out by appropriate Gram stain and culture of the same specimen of synovial fluid obtained for examination with the polarizing microscope

What is the definitive diagnostic test of choice for this patient's disease? A a plasma level B a random urine test C a 24-hour urine test D a synovial fluid analysis E Gram stain plus culture and sensitivity

Allopurinol, colchicine

What is the medical treatment for gout?

B decreased renal excretion of uric acid Decreased renal excretion of uric acid is the cause of primary gout in 75% to 90% of patients, whereas uric acid overproduction accounts for the other 10% to 25% of cases. Secondary causes of gout include chronic renal disease, acute ethanol ingestion, low-dose salicylates (they are uricosuric at high doses), and diuretics, especially the thiazide type. The most common cause of overproduction of uric acid is a myeloproliferative or lymphoproliferative disorder. In addition, when a patient is undergoing cancer chemotherapy, there is a significant liberation of uric acid from dying cells. The greater the responsiveness of the tumor to chemotherapy or radiotherapy, the quicker the tumor breakdown and the more extensive the breakdown of uric acid. Colchicine has many gastrointestinal side effects, particularly diarrhea, that limit its usefulness.

What is the most common metabolic abnormality found in patients with gout? A increased production of uric acid B decreased renal excretion of uric acid C increased production of uric acid metabolites D decreased renal excretion of uric acid metabolites

>7.5

What uric acid level helps to confirm a diagnosis of gout?

E all of the above chronic pyrophosphate deposition can be caused by any condition that provides a local nucleation site for formation of calcium pyrophosphate crystals, probably by initial precipitation of apatite with subsequent conversion, or by conditions that increase serum phosphate levels until precipitates form at vulnerable sites. Trauma and surgery are likely to create nucleation sites prone to such crystallization, whereas hemochromatosis and hyperparathyroidism tend to increase the serum phosphate level. Diabetes mellitus and hypothyroidism are other endocrine disorders associated with an increased risk for development of CPDD. Many cases appear not to be associated with any known risk factors but possibly are the result of some forgotten, relatively mild trauma. Prevalence increases with age, having been reported to be 3% or 4% in patients younger than 60 years, as high as 25% in individuals in their 80s, and 50% in patients older than 90 years. It is also said to be seen approximately half as often as gout in the typical primary care office setting. Symptoms tend to resolve with conservative treatment consisting of rest and use of antiinflammatory drugs. Intraarticular steroid injections are usually helpful in otherwise intractable cases. Rarely, surgery, in which the crystals are scraped off of the soft tissues, is used as a last resort.

Which of the following conditions predispose(s) individuals toward pseudogout? A hemochromatosis B hyperparathyroidism C trauma D surgery E all of the above