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Rheumatology YR3 > Crystal arthropathies > Flashcards

Crystal arthropathies Flashcards

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1
Q

What is gout?

A
  • Inflammatory arthiritis related to hyperuricaemia
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2
Q

Joints affected in gout

A

Acute gout can affect 1 or more joints but most commonly involves the 1st metatarsophalangeal joint (big toe aka podagra)

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3
Q

Pathophysiology of gout

A

Deposition of monosodium urate crystals that accumulate in joints and soft tissues, resulting:
* Acute and chronic arthirits
* Soft tissue masses called tophi
* Urate nephropathy
* Uric acid nephrolithiasis

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4
Q

What is common after initial flare of gout?

A

Second flare up occurs in 60% of patients within 1 yr and 78% within 2yrs of initial attack

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5
Q

Management of gout overall, non specific

A
  • Treat acute attacks
  • Prevent recurrent disease - long term reduction in uric acid levels by meds and lifestyle
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6
Q

Risk of gout

A

Associated with high risk of CVD

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7
Q

Risk factors of gout - non modifiable

A
  • Age older than 40
  • Male
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8
Q

Modifiable risk factors for gout

A
  • Increased purine intake (urate is metabolite of purines) eg red meat and seafood
  • Alcohol intake (esp beer)
  • High fructose intaje
  • Obesity
  • Congestive HF
  • Coronary artery disease
  • Dyslipidaemia
  • Renal disease - CKD
  • Organ transplant
  • HTN
  • Smoking
  • Diabetes mellitus
  • Urate elevating medications eg thiazide and loop diuretics
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9
Q

Investigations for gout

A

Joint aspiration - rules out infection, can see crystals

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10
Q

Treatment gout - conservative

A
  • Maintain optimal weight
  • Regular exercise
  • Diet modification - reduce purine rich foods
  • Reduce alcohol consumption - beer and liqour
  • Smoking cessation
  • Maintain fluid intake and avoid dehydration
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11
Q

Appearance of gout crystals under microscope

A

Needle shaped crystals which are yellow - negatively birefringent through polarised light

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12
Q

First line pharmacological managaement for gout acutely

A
  • NSAIDs - often naproxen
  • Oral/IM steroids
  • Colchicine
  • Recombinant uricase - but often people have reaction to this
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13
Q

What scenario can we not give naproxen?

A
  • AKI/CKD
  • Bleeding/stomach ulcers
  • HF
  • Asthma - sometimes react

If cannot have - often have steroids

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14
Q

Side effects of colchicine

A
  • GI side effects - nausea, vomitting
  • Pancytopenia
  • Need to decrease dose in CKD
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15
Q

Who do we need to take precautions giving steroids to?

A
  • Diabetic patients - increases BMs
  • HF
  • Bleeding
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16
Q

Examination findings of someone with gout

A
  • Hot tender joint - 1st MTP usually but cna be polyarticualr
  • Tophi
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17
Q

How does colchicine work?

A

Stops neutrophils adhering to endothelium
Decreases inflammation

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18
Q

What are tophi?

A
  • Depositions of urate crystals in soft tissue
  • Often found in fingers and ear around helix area
  • Sign of chronic gout
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19
Q

Long term pharmacological therapy for chronic gout

A

Urate lowering therapy eg allopurinol and febuxostat (F in HF or if allo not working)
These are commenced usually 2 weeks after flare up

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20
Q

What is intercritical gout?

A

Between attacks of gout - had a flare but better now

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21
Q

How do allopurinol and febuxostat work?

Study These Flashcards
A
  • Xanthine oxidase inhibitors
  • Reduce urate formation
22
Q

Less commonly used pahrmacological management of chronic gout

Study These Flashcards
A
  • Benzbromarone
  • Sulfinpyrazone
  • Less used as more side effects
  • But these increase renal excretion of uric acid
23
Q

Aim of urate lowering medications

Study These Flashcards
A

Aim to reduce serum uric acid to less than 360 micromol/L

24
Q

When should pharmacological management of acute gout be started?

Study These Flashcards
A

Begin within 24hrs of flare up as it is highly effective then

25
what happens if a pt has hyperuricaemia with no symptoms?
No treatment is needed
26
What type of crystals are found in aspirate for gout?
Monosodium urate crystals - only in gout, diagnostic
27
Diagnosis of gout needs..
Joint aspiration
28
Differential diagnosis of gout
* Septic arthirits - monoarthiritis you should always consider * Pseudogout
29
What crystals are present in pseudogout?
Calcium pyrophosphate crystals
30
Who does psuedogout most commonly affect?
Older women with OA
31
How does gout present?
* Single hot joint
32
Why does gout affect males more than pre-menopausal females?
Oestrogen increases excretion of uric acid in urine
33
Usual resolution of acute gout
* Flare up resolves within 3-10 days * Can reoccur and spread to other joints * Can get rebound gout if stop treatment and gout is bad again - not fully treated
34
Uric acid blood test results during gout
* Can be high - shows gout * Can be low - as can be consumed when being deposited in joint spaces * So cannot really use as a measure
35
Whats podagra?
Gout of 1st MTP
36
X-ray appearance of gout
Punched out regions at edges of joints - erosions Sclerosis often around these lesions Like caterpillar eating a leaf
37
What can we not give allopurinol alongiside and why?
* Azathioprine * Allopurinol inhibits xanthine oxidase which breaks down azathioprine * Can overdose on azathioprine
38
What can xanthine oxidase's trigger so what must we do?
* Gout flare up - destabilses crystals as lowers serum urate so crystals break down * Must take NSAID/colchicine for 6 months when starting these
39
Indications for allopurinol (long term serum urate reducing medications)
* Tophi * Frequent attacks * Urate caused kidney damage CKD * Erosive joint disease
40
Side effect of allopurinol
* Need to decrease dose in CKD * Rash * Allopurinol hypersensitivity syndrome
41
What is allopurinol hypersensitivity syndrome, how does it present?
* Fever * Rash * Kidney failure * Leukocytosis * Eosinophilia * Abnormal LFTs
42
Risk factors for pseudogout
* Hyperparathyroidism * Familial hypocalciuric hypercalcaemia * Haemochromatosis * Hypothyroidism * Hypomagnesia * Hypophosphataemia * Gout * Ageing * Amyloidosis * Trauma * Neuropathic joints
43
Radiological sign of pseudogout
* Milwaukee shoulder * Chondrocalcinosis
44
What is Milwaukee shoulder?
Depositions of crystals within synovium - synovial space no longer black, filled with crystals
45
What is chondrocalcinosis?
Calcification of cartilage between joints - calcium pyrophosphate deposition
46
Pseudogout vs gout under microscope
* Gout - needle shaped crystals (negative birefingent) * Pseudogout - more square shaped (rhomboid and positive birefingent)
47
Other than monosodium urate crystals in joint aspirate/tophi, other critria for gout diagnosis
Six or more of the following apply: * More than one attack of acute arthritis. * Maximum inflammation developed within 1 day. * Monoarthritis attack, redness observed over joints. * First metatarsophalangeal joint painful or swollen. * Unilateral first metatarsophalangeal joint attack. * Unilateral tarsal joint attack. * Tophus (confirmed or suspected). * Hyperuricaemia. * Asymmetrical swelling within a joint on X-ray film. * Subcortical cyst without erosions on X-ray film. * Joint culture negative for organism during attack.
48
Where are tophi commonly located?
Extensors - eg elbow, knee, achilles tendon or sometimes behind ear
49
When is urate lowering therapy recommended to be commenced?
* If have 2 or more attacks per year * If renal disease * Tophi * Uric acid renal stones * Prophylaxis if on diuretics or cytotoxics
50

Rheumatology YR3 (18 decks)

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