Crystal arthropathies

Question 1

Characterised by ?

Answer 1

deposition of mineralised material within joints and peri-articular tissue
COMMON

Question 2

Common crystal deposition diseases (3)

Answer 2

Monosodium urate - gout

Calcium pyrophosphate dihydrate (CPPD) - Pseudogout

Basic calcium phosphate hydroxy-apatite (BCP) – calcific periarthritis/tendonitis

Question 3

2/3 of urate in body comes from

Answer 3

purine metabolism

Question 4

urate excreted in ?

Answer 4

70% kidney

30% biliary tract

Question 5

reduced renal clearance of urine is most common cause of?

Answer 5

hyperuricaemia

Question 6

hyperuricaemia - overproduction

Answer 6

malignancies, tumour lysis, chemo patients (high cell turnover and break down)

• psoriasis and gout
• alcohol
• inborn erros or metabolism

Question 7

hyperuricaemia - overproduction deficiency ?

Answer 7

HGPRT

Question 8

hyperuricaemia - UNDEREXCTRETION (6)

Answer 8

• renal impairment
• hypetension
• hypothyroidism
• drugs - alcohol, aspirin
• exercise, starvation, dehydration
• lead poisoning

over indulgence in alcohol

Question 9

Genetic problems? Lesch nyan syndrome deficiency?

• features of this syndrome

Answer 9

HGPRT
- X linked recessive

• self mutation
• gout
• renal disease
• aggressive and impulse behaviour
• intellectual disability

Question 10

Gout is more common in?

Answer 10

men

Question 11

Hypoxanthine-guanine phosphoribosyl transferase (HPRT) normally plays a key role in the ?

Answer 11

recycling of the purine bases, hypoxanthine and guanine, into the purine nucleotide pools.

Question 12

Absence of HPRT

Answer 12

purine bases cannot be salvaged; instead, they are degraded and excreted as uric acid

• synthetic rates for purines is accelerated - compensates for loss - overproduction of uric acid

Question 13

Classic history of gout?

Answer 13

more sun exposure, alcohol, dehydrated

Question 14

Episodes often occur in what joint?

Often starts?

Answer 14

MTP

OVERNIGHT

Question 15

Episodes often occur in what joint?
Often starts?

episodes last how long?

Answer 15

MTP

OVERNIGHT

5-7 days - erythema of skin, hot and shiny

Question 16

Tophi are see over - what causes this?

Answer 16

bony surfaces

• white appearance during skin
• massive accumulation of uric acid

Question 17

Investigation of gout

Answer 17

aspirate the joint

Question 18

What would yo used under microscope for gout?

Answer 18

crystals

Question 19

Management of Gout - acute flare

Answer 19

NSAIDs
Colchicine - diarrhoea
Steroids - I/A, I/M, oral

Question 20

Management of Gout - HYPERURICAEMIA??

a 1st attack is not treated unless? (3)

Answer 20

Single attack of polyarticular gout
Tophaceous gout
Urate calculi
Renal insufficiency

-Prophylactically prior to treating certain

Question 21

What do we not treat?

Answer 21

asymptomatic hyperuricaemia

Question 22

Lowering uric acid - commonly used drugs? (4)

Answer 22

Allopurinol

Febuxostat - avoid in patients with cardiac history

Uricosuric agents e.g. sulphinpyrazone, probenecid, benzbromarone

Canakinumab

Question 23

Rules for lowering uric acid levels? (3)

Answer 23

• Wait until the acute attack has settled before attempting to reduce the urate level
• Use prophylactic NSAIDs or low dose colchicine/steroids until urate level normal
• Adjust allopurinol dose according to renal function - (increase it up monthly)

Question 24

really important in patients with gout to assess?

Answer 24

cardiovascular and lifestyle factors

Question 25

Pseudogout - joint? who does it typically effect? flares are often?

Answer 25

knee older women erratic

Question 26

triggers of Pseudogout

Answer 26

Trauma, Intercurrent illness

Question 27

In pseudogout you see?

Answer 27

Chondrocalcinosis on an XRAY

Question 28

Aspirating joint in Pseudogout - what will you see?

Answer 28

rhomboid crystals | hard to find

Question 29

Management of Pseudogout? (3)

Answer 29

NSAIDs I/A steroids (inter articular) There are no prophylactic therapies

Question 30

Polymyalgia Rheumatica is a? | close relationship with?

Answer 30

inflammatory condition of the elderly - giant cell arteritis (high serum anaemia)

Question 31

Polymyalgia Rheumatica - how many patients may have evidence of GCA

Answer 31

20%

Question 32

Polymyalgia Rheumatica - symptoms (5) female to male ratio?

Answer 32

sudden onset - shoulder +/- pelvic girdle STIFFNESS - anaemia - malaise, WL, fever, depression - Arthralgia / synovitis occasionally - usually in over 70's 2:1

Question 33

Polymyalgia Rheumatica - diagnosis ESR greater than?

Answer 33

``` Compatible history Age > 50 ESR > 50 Dramatic steroid response 9n 48 hours No specific diagnostic test ```

Question 34

Differential diagnosis of Polymyalgia Rheumatica? give examples of what it could be? (6)

Answer 34

- Myalgic onset Inflammatory joint disease - Underlying malignancy e. g Multiple myeloma, lung cancer - Inflammatory muscle disease (mysitis) - Hypo/ hyperthyroidism - Bilateral shoulder capsulitis (can present with stiff shoulders) - Fibromyalgia - look for temporal artery tenderness

Question 35

Polymyalgia Rheumatica? - treatment (3) under 65's and over 65's?

Answer 35

- Prednisolone 15mg per day initially - often start on that for 4 weeks - 18-24 mth course - Bone prophylaxis in under 65's - DXA scan over 65's - fractures - bone protection along with the steroids

Question 36

. In the vast majority of people with gout, hyperuricaemia results from ?

Answer 36

reduced efficiency of renal urate clearance