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Flashcards in Gout Deck (13)
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1
Q

Discuss the classification of gout.

A

Primary gout:

a. 95% of cases
b. genetic disorder characterised by uric acid.
c. Overproduction
d. under-secretion
e. occurs in elderly males and has a strong familial tendency

Secondary gout:

a. 5% of case
b. is due to acquired condition which cause uric acid
c. overproduction
d. under-secretion

2
Q

Can pharmaceuticals cause gout? Discuss briefly.

A

Many drugs may induce acute gout by their effect on uric acid levels eg some diuretics and salicylates cause increased tubular reabsorption of uric acid.

3
Q

Briefly discuss the pathology of acute gouty arthritis.

A
  1. Urate crystals are deposited in minute clumps in connective tissues (including articular cartilage).
  2. These crystals remain within the connective tissue sites for a period of time.
  3. Local trauma causes dispersion of crystals into the joint/surrounding tissues.
  4. The crystals evoke an acute inflammatory response by:
    • stimulating increased synthesis of inflammatory mediators
    • phagocytosis of crystals by neutrophils results in release of lysosomal products which results in the attraction of further WBC’s etc
    • phagocytosis of crystals by macrophages results in secretion of IL-1(a potent inflammatory mediator)
  5. The urate crystals that evoke the acute attack of gouty arthritis are:
    • microcrystals
    • birefringent (under polarised light)
    • needle shaped
4
Q

Briefly discuss the pathology of chronic tophaceous gout.

A
  1. With time recurrent attacks of acute arthritis occur.
2. A gradual build up of urate deposits occurs in:
•	joints   
•	tendons   
•	non articular tissues
•	periarticular tissues   
•	bursae
  1. The build up of urate deposits in the joints results in:
    • synovial proliferation
    • pannus formation
  2. Pannus formation results in:
    • destruction of underlying articular cartilage
    • eventual destruction of subchondral bone
    • proliferation of marginal bone
5
Q

Write brief notes on tophi. What is their significance?

A

• Tophi result from chronic urate deposition in various tissues and the ensuing chronic inflammatory response
• Tophi are pathognomonic for gout.
• Common sites of occurrence:
o around the metatarsophalangeal joints of big toes
o Achilles tendons
o olecranon bursae
o pinnae of ears (ie in cartilage)
• Tophi vary in size from 1 mm to several cm in diameter.

6
Q

Describe the typical (stereotypical) gout patient.

A
  • males
  • family history of gout
  • red faced shitfaced
  • > 30 years
  • obese
  • hypertensive
7
Q

Discuss the clinical manifestations of acute gout.

A

a. sudden onset of severe joint pain (often nocturnal)
b. joint pain lasts a few days.

Attacks are typically limited to a single joint, however more than one site may be affected.

The skin over the affected part is:
•	tense   
•	red or purplish   
•	shiny   
•	warm   
•	very swollen 

The joint:
• feels hot
• is extremely tender
• is limitation in motion

→ atypical presentations eg: acute pain tenderness ( in heel or sole)

8
Q

Discuss the clinical course of acute gout.

A

• condition progresses:
o acute attacks last longer ie pain may last weeks
o asymptomatic intervals begin to become shorter eg typically have several attacks/year
o gradually merges into chronic gouty arthritis

9
Q

Discuss the clinical manifestations of chronic gout.

A

• Recurrent acute attacks may eventually merge into polyarticular gout.

• Joint erosion results in:
o chronic pain
o stiffness
o deformity

• Tophi may be discovered; large tophi may ulcerate through the skin and discharge chalky material.

• In chronic gout we may observe the following renal manifestations:
o calculi: occur in 10-20% of cases
o parenchymal disease (due to deposition of MSU from blood) may result in renal failure
o renal tophi

10
Q

How is gout diagnosed?

A
  • usually based on the clinical picture and physical examination.
  • Presence of negatively birefringent urate crystals in the synovial fluid or in phagocytes → DIAGNOSTIC of gout.
11
Q

List the radiological features of chronic gout.

A

Acute attack: soft tissue swelling.

Chronic gout, may observe:
• joint space narrowing
• secondary OA
• tophi
• characteristic punched out cysts/deep erosions in the para-articular bone ends
• in severe cases bone erosion is marked and resembles neoplasia

12
Q

Briefly discuss the prognosis of gout.

A
  • most patients to live a normal life when the diagnosis is made early and treatment instituted quickly.
  • more severe in patients whose initial symptoms and signs appear before 30 years of age.
13
Q

List the complications of gout.

A
  • urolithiasis
  • urinary tract infection
  • urinary tract obstruction
  • renal tubulointerstitial disease