crystalline arthropathy (gout)

Question 1

what is gout

Answer 1

uric acid (monosodium urate) deposits in soft tissues, joints and bones

Question 2

6 diseases that causes secondary hyperuricemia

Answer 2

lymphoproliferative disorders
psoriasis
CHF
CKD
preeclampsia
dehydration

Question 3

4 drugs causing secondary hyperuricemia

Answer 3

thiazides
furosemide
aspirin
teriparatide
chemotherapy

+ pyrazinamide & ethambutol

Question 4

when can you treat asymptomatic hyperuricemia with urate-lowering agents

Answer 4

persistent in the infrequent patient with serum urate over 13 mg/dl (men) or 10 mg/dl (women)

Question 5

severe, sudden, disabling symptoms with intensity by 12-24hrs and resolves in days to weeks +/- treatment

Answer 5

acute gouty arthritis

Question 6

which condition has predilection to LE, with MTP being the first joint then midfoot then ankle?

Answer 6

acute gouty arthritis

Question 7

some predisposing/triggering factors to gout (5)

Answer 7

• trauma
• surgery
• starvation or dehydration
• dietary overindulgence
• drugs that raise or lower serum urate–allopurinaol, uricosuric agents, thiazide or loop diuretics, low dose aspirin

Question 8

of these 7 things, we need 6+ points to be able to make clinical diagnosis of gout.. list the 7 things.

Answer 8

• serum uric acid over 5.88 = 3.5 pts
• first MTP joint = 2.5 pts
• male = 2
• previous attack = 2
• HTN or a CVD = 1.5 points
• joint redness = 1 point
• onset w/in one day = 0.5 point

Question 9

what is the condition?

on microscopy– negatively birefringent needle-shaped crystles with increased WBC count (under 50K)

Answer 9

gout

Question 10

confirmatory diagnostic test for both gout and pseudogout

Answer 10

arthrocentesis

Question 11

what stage of gout

asymptomatic between attacks but will likely have second attack w/in 2 yrs if untreated
might end with chronic tophaceous gout if untreated

Answer 11

intercritical gout

Question 12

Gout crystals anywhere in soft tissue deep in skin. you poke it and it comes out like toothpaste

Answer 12

tophaceous gout

Question 13

first line tx of acute gout? who can’t get this treatment? if they cant get it then what?

Answer 13

• ist line: high dose NSAID
• NSAID C/I: renal insufficiency, active DU or GU, CVD
• instead give them steroids (intraaricular if under 2 joints or oral prednisone 30-50mg, taper over 10 days)

Question 14

when is colchicine used in gout? (2) when is it avoided? (1)

Answer 14

• acute: if its worked in the past and they can’t use an NSAIDs; works weakly in acute cases though
• can also be used as 2nd line in chronic gout
• avoid in kidney disease

Question 15

ADR of diarrhea, bone marrow suppression (neutropenia)

Answer 15

colchicine

Question 16

what is the condition

radiograph shows punched out erosions with sclerotic & overhanging margins– mouse/rat bite lesions

Answer 16

gout– bone resorption secondary to tophi formation in the bone

Question 17

2 renal complications of hyperuricemia

Answer 17

renal stones/urolithiasis
chronic urate nephropathy

Question 18

6 indications fo urate-lowering therapy

Answer 18

• recurrent gouty attacks that affect patients life
• tophaceous gout
• renal stones d/t uric acid (24 hr urine to confirm)
• very high uric acid levels
• urate nephropathy
• tumor lysis syndrome

Question 19

what is the treatment target for uric acid when doing urate lowering therapy

Answer 19

below solubility of 6 mg/dL

Question 20

• xanthide oxidase inhibitor that causes decreased production of uric acid; first line prophylaxis for gout
• prevents urate nephropathy from tumor lysis syndrome
• Start w/ 100 mg daily when renal function above 40 & increase slowly

Answer 20

allopurinol

Question 21

ADR of rash, leukopenia or thrombocytopenia, diarrhea, drug fever

Answer 21

allopurinol

Question 22

what are the two urosurics not on our med list but can be used for chronic gout; C/I in renal failure & urate overproducers

Answer 22

probenecid
sulfinpyrazone

Question 23

clinical manifestations that happen bc of CCP deposition into cartilage of joints

Answer 23

calcium pyrophosphate deposition disease (CPPD)

Question 24

incidental finding of chondrocacinosis on radiograph or genu varus on P.E

Answer 24

asymptomatic CPPD

Question 25

self-limited acute or subacute arthritis attacks occasionally associated w/ systemic sx of fever, leukocytosis
- knees, wrists, elbows, MCP, shoulders, etc

Answer 25

pseudogout– tends to last longer than gout

Question 26

nonerosive, inflammatory arthritis where there is CPPD crystals in joint fluid; affects MCP & wrists; associated w/ fatigue and AM stiffness

Answer 26

pseudo-RA/ chronic CPP inflammatory arthritis—- real RA is erosive

Question 27

progressive disease +/- acute/subacute episodes of pseudogout; affects knees, first CMC, atypical joints (wrists, MCP joints, hips, shoulders, spine, patellofemoral joint)

Answer 27

pseudo OA
- real OA isn’t at the patellofemoral joint, affects the patellar

Question 28

4 conditions that might lead to chondrocalcinosis

Answer 28

hemochromatosis– younger males
hyperparathyroidism- older males
low Mg
hypophosphatasia

Question 29

similar to charcot joint; uncommon presentation of CPPD

Answer 29

pseudo-neuropathic joint disease

Question 30

micoscopy shows positively birefringent crystalls, rhomboid shaped & increased WBC (under 50K)

Answer 30

arthrocentesis of pseudogout

Question 31

radiograph shows linear calcification of cartilage to support diagnosis

Answer 31

pseudogout

Question 32

first line for acute pseudogout

Answer 32

1st line: intraarticular steroids if less than 2 joints; NSAIDs if over 2??

Question 33

1st & 2nd line for chronic pseudogout if having attacks more than 3x/yr

Answer 33

1st line: colchicine
2nd line: NSAIDs

Question 34

other than medication for pseudogout, what else can you do for prophylaxis of pseudogout

Answer 34

manage underlying disease– hyperparathyroidism, low lmg, hemochromatosis