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Clinical lectures > Gout and pseudogout > Flashcards

Gout and pseudogout Flashcards

epidemiology, pathophysiology, presentation, investigation, management and prognosis

1
Q

What is crystal arthropathy?

A

An inflammatory joint disorder resulting from deposition of crystals in the joint and surrounding soft tissues

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2
Q

What are the 2 types of crystal arthropathies?

A

Gout

Pseudogout/calcium pyrophosphate dihydrate (CPPD)

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3
Q

What is the difference between the crystals found in gout and pseudogout?

A

Gout is characterised by monosodium urate crystals

Pseudogout is characterised by calcium pyrophosphate crystals

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4
Q

What is the most common inflammatory arthritis in men over 40?

A

Gout

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5
Q

When in a women’s lifespan is gout most common?

A

Post-menopause

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6
Q

Why is gout most common in post-menopause stage then any other time in a woman’s life?

A

Oestrogen has an uricosuric effect (increases uric acid excretion)

Post-menopausal stage has decreased oestrogen levels, so excess uric acid isn’t excreted and builds up and crystallises

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7
Q

What is the prevalence of gout in individuals with comorbidities then prevalence of gout in individuals with no other conditions?

A

Gout is significantly more prevalent in individuals with comorbidities

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8
Q

Give 5 examples of common comorbidities of individuals with gout?

A

Hypertension, diabetes, CVD, Chronic Kidney Disease (CKD), obesity

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9
Q

Who amongst the ageing population is most likely to have severe gout attacks?

A

Individuals with medications to treat comorbidities

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10
Q

If an elderly individual takes diuretics to prevent heart failure, how can this increase the likelihood of gout attacks occuring?

A

Diuretics decrease uric acid excretion, so crystals can form

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11
Q

Is pseudogout more common in young or elderly populations?

A

Elderly populations, over 50 years old

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12
Q

What percentage of individuals aged 65-75 have pseudogout?

A

10-15%

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13
Q

What percentage of individuals aged over 85 have pseudogout?

A

30-60%

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14
Q

What condition does gout pathophysiology arise from, and define this condition?

A

Hyperuricaemia: abnormally high serum uric acid levels

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15
Q

What are the 2 types of uric acid production, and how can they cause hyperuicaemia?

A

Exogenous and endogenous uric acid overproduction can lead to build up of serum uric acid

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16
Q

What is exogenous uric acid production, and what type of purine precursor is used in the reaction?

A

Production of uric acid from exogenous purines, which are absorbed by body from consumed food

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17
Q

What is endogenous uric acid production, and what type of purine precursor is used in the reaction?

A

Production of uric acid from endogenous purines, which are made directly by body itself

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18
Q

How can high alcohol consumption/alcohol abuse cause hyperuricaemia?

A

Alcohol increases exogenous production of uric acid

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19
Q

What 2 groups of disorders increase endogenous production of uric acid, leading to hyperuricaemia?

A

Myeloproliferative

Lymphoproliferative

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20
Q

How can abnormal renal handling of urate result in hyperuricaemia?

A

Causes underexcretion of uric acid

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21
Q

What are 2 diseases that cause abnormal renal handling of urate?

A

Renal disease

Polycystic kidney disease

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22
Q

What percentage of individuals with hyperuricaemia/primary gout are underexcretors of uric acid?

A

90%

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23
Q

What are the 3 causes of hyperuricaemia that can result in gout?

A

Exogenous/endogenous overproduction of uric acid

Underexcretion of uric acid due to abnormal renal handling

Combination of overproduction and underexcretion of uric acid

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24
Q

Name 8 substances that cause hyperuricaemia (CANT LEAP)?

A

Cyclosporine
Alcohol
Nicotinic acid
Thiazides

Lasix (frusemide)
Ethambutol
Aspirin (low dose)
Pyrazinamide

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25
Q

How is monosodium urate formed from uric acid in gout?

A

Uric acid ions combine with sodium ions to from monosodium urate (a common salt)

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26
Q

How are calcium pyrophosphate crystals formed in pseudogout?

A

Excess pyrophosphate complexes combine with calcium

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27
Q

What is the pathophysiology of pseudogout?

A

Calcium pyrophosphate crystals form in joint cartilage, then are shed into synovial fluid in synovium/joint lining

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28
Q

In gout and pseudogout, what triggers inflammation of the joint/synovium?

A

Build up of crystals

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29
Q

What is the volume of synovial fluid in a normal knee joint compared to in a gouty/pseudogouty knee joint?

A

less than 3.5 ml in normal knee joint

More than 3.5 ml in gouty/pseudogouty knee joint

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30
Q

What is the viscosity of synovial fluid in a normal knee joint compared to in a gouty/pseudogouty knee joint?

A

Very high viscosity in normal knee joint

Very low viscosity in gouty/pseudogouty knee joint

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31
Q

What is the colour of synovial fluid in a normal knee joint compared to in a gouty/pseudogouty knee joint?

A

Clear synovial fluid in normal knee joint

Opaque, straw-coloured synovial fluid in gouty/pseudogouty knee joint

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32
Q

What is the WBC/mm3 of synovial fluid in a normal knee joint compared to in a gouty/pseudogouty knee joint?

A

200 mm3 in normal knee joint

Over 100,000mm3 in gouty/pseudogouty knee joint

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33
Q

What is the percentage of neutrophils composing synovial fluid in a normal knee joint compared to in a gouty/pseudogouty knee joint?

A

Less than 25% in normal knee joint

Over 50% in gouty/pseudogouty knee joint

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34
Q

What procedure is used to obtain a synovial fluid sample from a joint, and what are the steps?

A

Joint aspiration

Insert needle into joint and remove synovial fluid, send culture to lab

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35
Q

Give 3 factors that can be tested from a synovial fluid sample obtained from joint aspiration of an individual with gout/pseudogout?

A

Infection, this is necessary to rule out as it can permanently destroy joint

Inflammatory markers

Crystals so that condition can be distinguished between pseudogout and gout

36
Q

Give 6 examples of predisposing factors of gout?

A

Immediate postoperative period
Alcohol abuse
Local infection
Stroke
Large food intake high in purine
Fasting

37
Q

What are the 4 clinical phases of gout?

A

Asymptomatic hyperuricaemia
Acute gout attack
Intercritical gout
Chronic tophaceous gout

38
Q

What occurs in the asymptomatic hyperuricaemia phase of gout?

A

Serum uric acid level is elevated but there are no symptoms/signs of gout eg. no inflammation

39
Q

How can acute gout attacks be described in terms of when they occur in the day, onset and how they affect the joint?

A

Often occur in early morning or night with rapid onset and makes joints red, hot, swollen, tender

40
Q

Give 6 examples of joint commonly affected by acute gout attacks?

A

Ankle
Wrist
Hand
Knee
Big toe
Other toes

41
Q

Are acute gout attacks normally monoarticular or polyarticular?

A

Monoarticular

42
Q

What percentage of acute gout attacks are polyarticular?

A

10-15%

43
Q

In 50% of acute gout attack cases, what joint is initially affected?

A

1st metatarsophalangeal (MTP) joint (big toe)

44
Q

What is podagra?

A

Acute gout attack of 1st metatarsophalangeal joint (big toe)

45
Q

What is the intercritical gout phase?

A

Time between gout attacks where individual has no symptoms but monosodium urate crystals are still accumulating

46
Q

What occurs in the chronic tophaceous gout phase?

A

Large, white, solid bumps of monosodium urate crystals form under skin and over joints, cartilage, bones

47
Q

What is the difference in intercritical gout phases in acute gout and chronic gout?

A

In chronic gout, the intercritical gout phases are shorter (less time between attacks)

48
Q

What are the 4 ways in which pseudogout can present?

A

Asymptomatic chondrocalcinosis
Acute pseudogout
Pseudo-OA/CPPD with OA
Chronic pseudogout

49
Q

How does asymptomatic chondrocalcinosis occur?

A

Accumulation of calcium crystals in joint cartilage

50
Q

How is asymptomatic chondrocalcinosis diagnosed, and what joint does it normally affect?

A

Diagnosed as a radiographical imaging finding in asymptomatic pseudogout patients

Mostly affects knee joint

51
Q

How does pseudo-OA occur?

A

Pseudogout causes accelerated OA in joints not commonly affected by OA, such as MCP and elbow joints

52
Q

Is pseudo-OA more common in men or women?

A

Women

53
Q

What is the most common form of pseudogout when it presents as inflammatory?

A

Acute pseudogout

54
Q

What is acute pseudogout?

A

Sudden, self-limiting monoarthritis (1 large joint) or olgioarthritis (2-4 large joints), that is the most common form of inflammatory pseudogout

55
Q

How can you tell that there is joint inflammation in acute pseudogout?

A

Cardinal signs of inflammation

56
Q

Do acute pseudogout attacks affect men or women more?

A

Men

57
Q

What 7 joints are commonly affected by acute pseudogout?

A

Knee, wrist, shoulder, hip, ankle, elbow, toe

58
Q

What 3 factors can trigger acute pseudogout attacks?

A

Trauma
Surgery
Severe medical illness

59
Q

What is the difference between acute and chronic pseudogout, in terms of how many large joints are affected?

A

Acute is mono/oligoarthritic (1 or 2-4 large joints)

Chronic is polyarthritic (5 or more large joints)

60
Q

What 2 lab findings are used to diagnose gout?

A

Serum Uric acid is a negative acute phase reactant so has decreased level in gout attack, level should be re-checked 1-2 weeks after attack has settled and must be 360 micromol/L or more in remission period

polarised light microscopy of synovial fluid shows negatively birefringent, needle-shaped crystals

61
Q

How can urinalysis with a urine dipstick suggest gout?

A

hematuria

62
Q

What lab finding is used to diagnose pseudogout?

A

Polarised light microscopy of aspirated synovial fluid shows positively birefringent rhomboid-shaped crystals

63
Q

What are the 3 examples of lifestyle advice to give patients to manage gout?

A

Educating the patient to eat low-purine diet, less alcohol, lose weight to avoid obesity

64
Q

Give 5 examples of high-purine food?

A

Shellfish eg. scallops, mussels
alcohol
red meat
animal organs
fish

65
Q

Give 5 examples of medium-purine food?

A

Vegetables
legumes
lobster
crab
oyster

66
Q

Give the main 2 ways of managing an acute gout attack?

A

Joint rest and ice

Take a first-line drug

67
Q

What are the 3 first-line drugs of acute gout attacks, and when is each drug used?

A

NSAIDs or COX II inhibitors are used first

Oral colchicine used if NSAIDs or COX II inhibitors are contraindicated

Local corticosteroid injection used if oral colchicine is contraindicated

68
Q

What are the first and second line drug classes to manage intercritical gout?

A

First-line is xanthine oxidase inhibitors

Second-line is uricosuric agents

69
Q

What is the first-line drug used for intercritical gout, and what is its alternative drug?

A

Allopurinol, but febuxostat is an alternative drug is allopurinol isn’t well-tolerated

70
Q

Give 3 examples of uricosuric agents that are second-line drugs for intercritical gout?

A

probenecid, sulfinpyrazone, benzbromarone

71
Q

Why is colchicine prophylaxis used with allopurinol to treat intercritical gout, and how long is it used for with allopurinol?

A

Colchicine prophylaxis used for first 3-6 months of allopurinol, as allopurinol increases chances of gout flare up in first few months of use

72
Q

Give 3 side effects of allopurinol when used to treat intercritical gout?

A

Rashes, hepatotoxicity, hypersensitivity

73
Q

What is a side effect of uricosuric agents when they are used to treat intercritical gout?

A

Increased risk of uric acid stone formation

74
Q

Which 2 uricosuric agents are ineffective in treating intercritical gout when the individual has CKD?

A

Sulfinpyrazone and probenecid

75
Q

What 3 antihypertensive drugs decrease chance of gout flares?

A

losartan, fenofibrate, atorvastatin

76
Q

How is asymptomatic chondrocalcinosis treated?

A

It isn’t treated as it usually settles itself

77
Q

What are the 2 steps of managing acute pseudogout?

A

Joint aspiration

Local corticosteroid injection

78
Q

What 2 drugs can be used to manage chronic pseudogout?

A

NSAIDs, corticosteroids

79
Q

To manage chronic pseudogout, what needs to be treated other than the pseudogout itself?

A

Associated diseases

80
Q

Give examples of predisposing factors to pseudogout?

A

Aging
Hyperparathyroidism
Hemochromatosis
Hypomagnesemia
Hypophosphatasia
May follow parathyroidectomy
Acromegaly
Hypothyroidism
Trauma
Infection
Osteoarthritis

81
Q

What stage of gout is associated with bone erosion?

A

Chronic tophaceous gout

82
Q

Give 4 characteristic features of the bone erosion caused by chronic tophaceous gout?

A

Well defined erosion
Sclerotic borders
Overhanging edges
No osteoporotic bone

83
Q

What are 4 radiological findings that are associated with CPPD?

A

Triangular fibrocartilage calcification (calcification of stabilising joint at wrist)

Subchondral sclerosis: hardening of bone below cartilage, common in load-bearing joints, common in OA

Joint space narrowing

Subchondral cyst formations

84
Q

What are 6 differential diagnoses of gout?

A

RA
OA
PsA
ReA
Septic arthritis
Pseudogout

85
Q

What are the 6 differential diagnoses of pseudogout?

A

RA
OA
PsA
ReA
Septic arthritis
Gout

86
Q

How can pseudogout and gout be differentiated from RA?

A

RA has different degree of inflammation

87
Q

How can pseudogout and gout be differentiated from septic arthritis?

A

Synovial fluid culture is tested for infectious agents that cause septic arthritis

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