Crystal Arthropathy Flashcards
Common crystal deposition diseases: pathology + common diseases
• DEPOSITION of MINERALISED MATERIAL w/i JOINTS & PERI-ARTICULAR DISEASE
GOUT = MONOSODIUM URATE
PSEUDOGOUT = CALCIUM PYROPHOSPHATE DIHYDRATE (CPPD)
CALCIFIC PERIARTHRITIS/TENDONITIS = BASIC CALCIUM PHOSPHATE HYDROXY-APATITE (BCP)
Gout: presentation
- ACUTE SUDDEN ONSET
- UNTREATED = FLARE UP FOR 7-10 DAYS + RESOLVES; EPISODIC
- DEHYDRATED, ALCOHOL, DIURETICS, BEEN IN THE SUN
- WARMTH
- PAIN
- SWELLING
- EXTREME TENDERNESS
Gout: investigations/diagnosis
Hx + examination:
• TOEPHI
• ACUTE HOT SWOLLEN JOINT
DDx:
• SEPTIC ARTHRITIS - esp. if other factors present (immunosuppressant e.g. rheumatic disease)
- OA FLARE-UP
- ABNORMAL JOINT already present
Investigations:
• SERUM URIC ACID LVLS = not as useful in an acute episode
- JOINT ASPIRATION + POLARISING MICROSCOPY
- Joint aspiration = determine whether it’s infection or other cause
- Polarising microscopy = in gout, show -VELY BIREFRINGENT MICROCYRSTALS (they cause inflammation + irritation of joint lining)
Gout: management
Acute flare:
• NSAIDs
• COLCHICINE
* Works similarly to anti-inflammatory, but slower * Can get PROFUSE POLYURIA
- STEROIDS (INTRA-ARTICULAR (I/A), IM, ORAL - PREDNISOLONE)
- Esp. for POLYARTICULAR, EXCLUDE SEPTIC ARTHRITIS before administering
Hyperuricaemia:
DOES IT NEED TO BE TREATED?
1ST ATTACK UNTREATED UNLESS: risk factors implying another attack could occur
* SINGLE ATTACK of POLYARTICULAR GOUT * TOPHACEOUS GUT * URATE CALCULI * RENAL INSUFFICIENCY
TREAT if 2ND ATTACK W/I 1 YEAR
* ALLOPURINOL - for prophylaxis; xanthine oxidase inhibitor * FEBROXOSTAT - for prophylaxis, careful in cardiac pt. * URICOSURIC AGENTS - less freq. used; SULPHINPYRAZONE, PROBENECID, BENZBROMARONE * CANAKINUMAB - IL-1 antagonist
START ABOVE DRUGS FEW WEEKS AFTER ACUTE FLARE-UP - as they can PRECIPITATE GOUT ATTACK
Use PROPHYLACTIC NSAIDs or LOW DOSE COLCHICINE/STEROIDS UNTIL URATE LVLS NORMALISE (serum urate < 300 is ideal)
ADJUST ALLOPURINOL DOSE according to RENAL FUNCTION
PROPHYLACTICALLY PRIOR to TREATING CERTAIN MALIGNANCIES
DO NOT TREAT ASYMPTOMATIC HYPERURICAEMIA
Gout: epidemiology
• MALES»_space; FEMALES (AT ALL AGES)
○ RARE IN PRE-MENOPAUSAL WOMEN = OESTROGEN has URICOSURIC LVLS; AFTER MENOPAUSE = URATE LVLS RISE • INCREASES W/ AGE ○ HIGH BP = MORE LIKELY TO BE ON DIURETICS (& OTHER DRUGS that RAISE SERUM URIC ACID lvls; LOSARTAN can be used in hypertensive pt. w/ gout as it is URICOSURIC) ○ AGE-RELATED CHANGES in CONNECTIVE TISSUES - may ENCOURAGE CRYSTAL FORMATION ○ INCREASED PREVALENCE of OA ○ INCREASE in SERUM URIC ACID lvls (mainly due to reduced renal function)
Pseudogout: presentation
- KNEE
- ERRATIC FLARES
Pseudogout: aetiology
- IDIOPATHIC
- FAMILIAL
- METABOLIC
Pseudogout: triggers
- TRAUMA
* INTERCURRENT ILLNESS
Pseudogout: epidemiology
ELDERLY WOMEN
Pseudogout: investigations/diagnosis
X-RAY - CHONDROCALCINOSIS
ASPIRATE - PYROPHOSPHATE CRYSTALS (weakly birefringent)
exclude septic arthritis
Pseudogout: management
- NSAIDS
- INTRA-ARTICULAR STEROIDS (may not be best for some pt. e.g. if it may be septic arthritis)
POLYMYALGIA RHEUMATICA
• INFLAMMATORY CONDITION of the ELDERLY
PRESENTATION:
• SUDDEN ONSET SHOULDER +/- PELVIC GIRDLE STIFFNESS - difficulty in getting in & out of chair, lifting arms up, hanging washing ○ NO SWELLING * ANAEMIA * MALAISE, WGT. LOSS, FEVER = SYSTEMICALLY UNWELL ○ NEED TO ASK ABOUT GCA SYMPTOMS:
○ TEMPORAL PAIN, SCALP TENDERNESS - sore when combing hair ○ JAW CLAUDICATION/TENDERNESS ○ VISUAL DISTURBANCES ○ NIGHT SWEATS ○ FEVER
• ARTHRALGIA/SYNOVITIS occasionally
EPIDEMIOLOGY: ELDERLY FEMALE
* F >> M (2 : 1) * RARE < 50 YRS - usually > 70 YRS • Ass. w/ GIANT CELL ARTERITIS
INVESTIGATIONS/DIAGNOSIS:
Hx & EXAMINATION + DRAMATIC STEROID RESPONSE w/I 24-48hrs (if still symptomatic after a few weeks unlikely to be polymyalgia) - only need 15mg often enough (much higher for GCA), if steroids tapered too quickly will cause flare
BLOODS ESR > 45 usually; often 100
FBC
DIAGNOSIS COMPATIBLE Hx
AGE > 50 YRS ESR > 50 DRAMATIC STEROID RESPONSE NO SPECIFIC DIAGNOSTIC TEST
MANAGEMENT:
* PREDNISOLONE - 15 mg per day initially; 18 - 24 month course * BONE PROPHYLAXIS = DEXA SCAN ANYWAY + BISPHOSPHONATES IF HIGH RISK - may need to evaluate if they're req. for at lower risk pt.
DDX • MYALGIC ONSET INFLAMMATORY JOINT DISEASE (MOIJD) - if AS STEROIDS TAPERING - CAUSES JOINT SYMPTOMS TO BE MORE PROMINENT
* UNDERLYING MALIGNANCY - e.g. MULTIPLE MYELOMA, LUNG CANCER * INFLAMMATORY MUSCLE DISEASE - STIFFNESS + PAIN can HIDE INFLAMMATORY DISEASE (do CK) * HYPO/HYPERTHYROIDISM * BILATERAL SHOULDER CAPSULITIS * FIBROMYALGIA - CHORNIC PERSISTENT PAIN SYNDROMES
EPIDEMIOLOGY:
• MALES >> FEMALES (AT ALL AGES) ○ RARE IN PRE-MENOPAUSAL WOMEN = OESTROGEN has URICOSURIC LVLS; AFTER MENOPAUSE = URATE LVLS RISE • INCREASES W/ AGE ○ HIGH BP = MORE LIKELY TO BE ON DIURETICS (& OTHER DRUGS that RAISE SERUM URIC ACID lvls; LOSARTAN can be used in hypertensive pt. w/ gout as it is URICOSURIC) ○ AGE-RELATED CHANGES in CONNECTIVE TISSUES - may ENCOURAGE CRYSTAL FORMATION ○ INCREASED PREVALENCE of OA ○ INCREASE in SERUM URIC ACID lvls (mainly due to reduced renal function)
Pseudogout: management
- NSAIDS
- INTRA-ARTICULAR STEROIDS (may not be best for some pt. e.g. if it may be septic arthritis)
Polymyalgia rheumatica: presentation
• SUDDEN ONSET SHOULDER +/- PELVIC GIRDLE STIFFNESS - difficulty in getting in & out of chair, lifting arms up, hanging washing
○ NO SWELLING * ANAEMIA * MALAISE, WGT. LOSS, FEVER = SYSTEMICALLY UNWELL ○ NEED TO ASK ABOUT GCA SYMPTOMS:
○ TEMPORAL PAIN, SCALP TENDERNESS - sore when combing hair ○ JAW CLAUDICATION/TENDERNESS ○ VISUAL DISTURBANCES ○ NIGHT SWEATS ○ FEVER
• ARTHRALGIA/SYNOVITIS occasionally
Polymyalgia rheumatica: epidemiology
ELDERLY FEMALE
* F >> M (2 : 1) * RARE < 50 YRS - usually > 70 YRS • Ass. w/ GIANT CELL ARTERITIS
Polymyalgia rheumatica: investigations/diagnosis
Hx & EXAMINATION + DRAMATIC STEROID RESPONSE w/I 24-48hrs (if still symptomatic after a few weeks unlikely to be polymyalgia)
BLOODS: ESR (> 45), FBC
DIAGNOSIS: COMPATIBLE Hx, AGE > 50 YRS, ASR > 50, DRAMATIC STEROID RESPONSE, NO SPECIFIC DIAGNOSTIC TEST
