Crystalline Arthropathies Flashcards by Hannah Brule

How common is gout?

Common, about 2% of the population is affected

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Gout is one of a group of diseases characterized by ___ throughout the body

crystalline deposition

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What must be elevated in the blood to predispose gout?

Uric acid

normal byproduct of purine metabolism

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What type of patient is most likely to present with gout?
Why is this so?

Older (40-50s) males
Males produce more uric acid than females

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What are the crystals composed of in gout?

Uric acid

sodium monourate

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What are the etiologies of gout?

85% idiopathic impairment of renal uric acid excretion
Genetic (purine metabolism)
Stress
Alcoholism
Diabetes (long term)

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How might alcoholism lead to gout?

Beer and red wine increase purines, thus increasing uric acid
Can lead to renal disease, gout would be secondary to kidney issues

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What is the pathogenesis of gout?

Overproduction of purine metabolic byproducts (uric acid)
Inability to dispose of/break down metabolic byproducts

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A patient comes in for a routine urinalysis and has hyperuricemia, but does not report any related symptoms.
Do they have gout?

No gout

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A patient reports that their great toe is big, red, and swollen. They noticed this, along with other acute arthritis symptoms, shortly after a bout of alcohol consumption. Upon urinalysis, the patient has hyperuricemia.
What is the diagnosis?

Gout

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Primary gout is the case for ___ of patients with gout
What makes gout primary?

1/3
Etiology is metabolic overproduction of uric acid

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Secondary gout is the case for ___ of patients with gout
What makes gout secondary?

2/3
Underlying pathological etiology is present

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What are some underlying pathologies that can lead to secondary gout?

Multiple myeloma (protein in blood destroys kidneys)
Alcoholism
Diabetes (destroys kidneys)
Kidney disease

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In the pathogenesis of gout, uric acid crystals deposit in the soft tissue of an extremity joint.
What sort of pain will result from this?

Uric acid crystals are not irritating; found in asymptomatic joints

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gout

Urate crystals are phagocytized by ___

PMNs and macrophages

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gout

PMNs and macrophages try to phagocytize urate crystals, which induces a release of leukotrienes, cytokines, and chemotactins that elicit an intense ___

inflammatory reaction

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gout

PMNs and macrophages try to phagocytize urate crystals, which induces a release of ___, ___, and ___ that elicit an intense inflammatory reaction

leukotrienes, cytokines, and chemotactins

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How does chronic gout lead to joint destruction?

Lysosomes and other enzymes released

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If untreated, gout will generally resolve in about ___, but can recur ___ later

gout will generally resolve in about 1 week, but can recur months to years later

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What is the differential diagnosis for what grossly appears to be gout?

Septic arthritis

big, red, swollen joint; occurs quickly

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What is the differential diagnosis for septic arthritis presenting as a single swollen red joint in the lower extremity?

Gout

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What test differentiates gout from septic arthritis?

Joint aspiration:

Septic arthritis reveals purulent exudate
Gout appears clear with crystals

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90% of patients with gout have ___

acute arthritis

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How often is gout chronic?
What makes gout chronic?

10-15% chronic
Demonstrates pannus production and destruction

pannus production and destruction also presents with rheumatoid arthritis

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How many joints are usually affected by gout?

One or two ## Footnote often intially podagra (great toe)

Besides the great toe, what are some common locations for gout?

Peripheral joints: * Instep * Heel * Ankle * Knee * Wrist (not spine)

Which clinical manifestation is indicative of chronic gout?

Tophi (chalky deposit)

What are tophi?

A chalky deposit; monosodium urate (crystal) deposit in soft tissues | found in chronic gout ## Footnote develop over 10-20 years time

What are the cardinal signs of gout?

Rubor, calor, dolor, tumor | (all of them)

What is the pattern of pain with gout?

Begins at night and builds rapidly over 24 hours

What are some clinical manifestations of gout?

* Tophi * Cardinal signs * Pain at night, gets worse over a day * Hyperuricemia * Renal impairment in chronic cases

What are the 4 stages of gout?

1. Asymptomatic hyperuricemia 2. Acute gouty arthritis 3. Polyarticular gouty arthritis 4. Chronic tophaceous gout

How does chronic tophaceous gout characteristically appear?

Tophi presenting as lumpy bumpy joints

A patient presents with a red, swollen bump at their first metatarsophalangeal joint. What is your differential diagnosis?

* Septic arthritis (infection) * Gout * Rheumatoid arthritis ## Footnote infection can also be cellulitis, osteomyelitis, etc.

Does gout have to be in joints?

No, it is a soft tissue disease

What are three radiographic characteristics of gout?

* Marginal erosions * Periarticular erosions * Intraosseous erosions ## Footnote subchondral white line maintained

#gout What is a corticated erosion?

Marginal erosion: has an overhanging margin due to a longer remission period that allowed for some regrowth/repair

#gout What is a periarticular erosion?

Deposits from periarticular soft tissues erode the bone

#gout What is an intraosseous erosion?

Deposits within the bone (intraosseous tophus with or without calcification)

A patient's radiograph of their great toe reveals corticated marginal erosions, periarticular erosions, and intraosseous erosions around the metatarsophalangeal joint. What is your differential diagnosis?

Gout | erosion followed by remission ## Footnote rheumatoid arthritis and psoriatic arthritis have **non-corticated** margins

A patient's radiograph of their swollen elbow displays what looks like gouty crystals in the olecranon bursa. What is your differential diagnosis?

* Gout * Olecranon septic bursitis

Gout should first be treated with a low purine, high water intake diet and a referral to a rheumatologist. What are some drug therapies they might be prescribed?

* NSAIDs (early, short-term) * Corticosteroids (acute, short-term) * **Colchicine** * **Allopurinol** * Uloric | avoid corticosteroids for recurring gout

A patient comes in and reports that they take colchicine. Why might they be taking this medication?

Used for recurrent attacks of gout or acute CPPD

A patient comes in and reports that they take allopurinol. Why might they be taking this medication?

Inhibits xanthine oxidase, treats gout

Joint destruction due to gout is radiographically visible after ___.

7 years

A patient reports that they had a big, red, swollen heel that went away on its own in about a week without treatment. Was this more likely a case of gout or septic arthritis?

Gout | infection takes longer to heal

What is the defining pattern of gout recurrence?

Exacerbation and remission ## Footnote exacerbation will get longer and remission shorter

Both gout and septic arthritis will have increased white blood cells. What additional information about white blood cells differentiates the two?

Infectious disease (septic arthritis) has increased white blood cells with a **left shit** | gout has no wbc shift ## Footnote uric acid will also be normal in septic arthritis

What is the full name of CPPD?

Calcium Pyrophosphate Dihydrate Crystal Deposition Disease

CPPD deposition disease is also called ___

pseudogout

CPPD looks like ___ because it is a big, red, swollen joint with exacerbation and remission

gout and septic arthritis

CPPD entails ___ crystals in ___ leading to inflammation

**calcium pyrophosphate** crystals in hyaline and fibro-**cartilage**

Onset of CPPD occurs at ___ years of age and peaks at age ___

onset at 30 peak at 60

CPPD is experienced by ___ of those over age 85

half

What are four other joint pathologies that CPPD may simulate?

* Gout * Rheumatoid arthritis * Degenerative joint disease * Neuropathic arthropathy

Generally, gout precipitates in ___, CPPD precipitates in ___

soft tissue cartilage

What is a key difference between CPPD and rheumatoid arthritis?

Rheumatoid arthritis can be bilateral and symmetrical, CPPD cannot

What is a key difference between CPPD and DJD?

DJD is associated with deep, dull, achy pain CPPD is usually asymptomatic (at least early on)

What is a key difference between CPPD and neuropathic arthropathy?

NA has a slower destruction than CPPD

What are some etiologies of CPPD deposition disease?

* Idiopathic * Hereditary (rare) * Trauma * Metabolic disorders

Phagocytosis of CPPD crystals by ___ leads to release of inflammatory mediators

synovial fluid and neutrophils

Phagocytosis of CPPD crystal by synovial fluid and neutrophils leads to release of ___

inflammatory mediators

In the pathogenesis of CPPD deposition disease, attacks are initially ___, but become ___

**monoarticular**, but become **polyarticular**

Acute CPPD deposition disease attacks may be self-limiting lasting a day to several days. What is this similar to?

Gout

An acute CPPD deposition disease attack may be self-limiting. How might a severe attack resolve?

Involving peripheral and axial joints, resolves slowly over weeks

CPPD crystals may accumulate in which tissues?

* Synovial membranes (pseudogout) * Articular cartilage (chondrocalcinosis) (hyaline and fibrocartilage) * Tendons and ligaments

What are some clinical manifestations of CPPD deposition?

* Chronic progressive joint pain * Reduced ROM with stiffness * Crepitus

Joint destruction from CPPD will be seen radiographically within ___ years For gout, destruction will be seen after about ___ years

CPPD = 2 years Gout = 7 years

What are some radiographic characteristics of CPPD deposition disease?

* Cartilage, synovium, tendons, and/or ligament involvement * Crystal deposition in peripheral joints (knees, wrists, hands)

How does chondrocalcinosis appear radiographically?

Cartilage (hyaline or fibro-) is visible

# CPPD A patient's radiographs show bright cartilage in the knee. You think it's chondrocalcinosis, but you should rule out ___.

joint degeneration

A patient's radiographs show bright cartilage in the knee. What information would help you narrow your differential diagnosis?

* History: symptoms * Joint aspiration | labs aren't very helpful ## Footnote DDx: chondrocalcinosis/CPPD, joint degeneration

A patient's radiographs present calcification in the meniscus of the knee (fibrocartilage), the hyaline cartilage, and the synovial membrane. What is the likely diagnosis?

CPPD deposition disease | pyrophosphate arthropathy

What are five treatments that CPPD responds to?

* Rest * Joint protection * NSAIDs * Colchicine (in acute attacks) * Corticosteroids (only during exacerbation)

Would CPPD respond to DMARDs?

What is the long term for HADD?

(Calcium) Hydroxyapatite Deposition Disease

What is another condition that may be in the differential diagnosis of HADD?

CPPD

CPPD occurs in cartilage. Which tissues will HADD occur in?

Bursa, ligaments, and tendons | HADD a BLT

Calcium hydroxyapatite deposition disease is also known as ___

calcific tendinosis (most common deposit), calcific bursitis

HADD involves ___ deposition in leukocytes and mononuclear cells in joints and synovial fluid

hydroxyapatite

HADD involves hydroxyapatite deposition in ___ and ___ in joints and synovial fluid

leukocytes and mononuclear cells

Where in the joint might calcification occur if a patient has HADD?

Within tendon, bursa, capsule, or ligament

What are the typical etiologies of HADD?

Post-traumatic / degenerative nature

Where in the body might calcification occur if a patient has HADD?

* Most commonly shoulder (rotator cuff) * Hip * Cervical spine

How might HADD in the shoulder present?

Presents as supraspinatus tendinosis | rotator cuff symptoms

How might HADD in the cervical spine present?

Presents in longus coli tendon for around 2 weeks | presents like torticollis ## Footnote cannot treat, refer for pain management

HADD may be asymptomatic at first What symptoms follow?

Painful attacks lasting days to months

HADD has been shown to respond well to ___

ultrasound (or shock wave) to break up calcium

What age group is most commonly affected by HADD?

Patients over 40-years-old

If a patient's radiographs present with calcifications in the bursa and capsule of their shoulder, what is the likely diagnosis?

HADD (calcium hydroxyapatite deposition disease)

Is gout inflammatory?

Yes

Is HADD inflammatory?

Yes

Is CPPD inflammatory?

Yes

Crystalline Arthropathies Flashcards

(93 cards)