gout and pseudogout

Question 1

what is gout ?

Answer 1

clinical syndrome caused by inflammatory response to monosodium urate monohydrate crystals which develops secondary to hyperurecemia

Question 2

when is it rare to see gout ?

Answer 2

in premenopausal women and in children

Question 3

what is the level where we can say a patient is hyperuremic ?

Answer 3

> 6 mg/dl or >360umol

Question 4

what is uric acid a metabolite of ?

Answer 4

purine -> hypoxanthine -> xanthine -> uric acid

Question 5

what are the classification of hyperuricemia ?

Answer 5

underexcretion

overproduction

Question 6

what are the causes of underexcretion ?

Answer 6

chronic renal failure
drugs ( CAN’T LEAP)
cyclosporin, alcohol, nicotinic acid, thiazides, lasix ethambutol, aspirin, pyrazinamide
idiopathic or genetic

Question 7

what are the causes of overproduction ?

Answer 7

polycythemia 
leukemia 
chronic hemolytic anemia 
psoriasis 
cytotoxic drugs used in malignancy ( tumor lysis syndrome)

Question 8

what are the 3 stages of presentation of gout ?

Answer 8

acute attack
intercritical period
arthropathy / nephropathy

Question 9

what is the presentation of acute gout ?

Answer 9

affecting the base of the big toe
usually monoarticular
rapid onset with swelling pain and erythema
may have normal urate levels during the attack
fever
raised WCC ESR

Question 10

where are the non articular depositions in acute gout ?

Answer 10

olecranon bursa and achilles tendon

achilles tendon

Question 11

what drug should be avoided in an acute attack of gout ?

Answer 11

allopurinol, prolongs attack

Question 12

what is the presentation of chronic gout ?

Answer 12

main presentation includes the presence of tophi
tophaceous gout

Question 13

where can we find tophi ?

Answer 13

helix of the ear 
fingers 
eyelids
olecranon bursa 
achilles tendon

Question 14

how do urate crystals appear under polarized light microscopy ?

Answer 14

needle shaped crystals that appear bright yellow (strongly bifrengent)

Question 15

what are the radiological findings in acute on chronic gout ?

Answer 15

punched out well defined lesion
subarticular cysts
joint space narrowing

Question 16

what are the radiological findings inn acute gout ?

Answer 16

soft tissue swelling around the first MTP

Question 17

what is important about the introduction or withdrawal of hypouricemic drugs during attack ?

Answer 17

the introduction or withdrawal of these drugs cannot be done without the use of colchine/NSAIDs as urate levels may change during the attack

Question 18

how to treat an acute attack ?

Answer 18

cold pack, rest
anti-inflammatory
colchine
short course of oral steroids

Question 19

what is the main side effect of colchine ?

Answer 19

GIT intolerance - diarrhea

Question 20

what are the indications of giving hypouricemic drugs ?

Answer 20

tophaceous gout 
radiographic erosions 
uric acid nephrolithiasis 
urate nephropathy 
recurrent attacks of gout ( 2 attacks a year)

Question 21

asymptomatic hyperuricemia do we give hypouricemic drugs ?

Answer 21

nope , but modify the risk factors

Question 22

what are the xanthine oxidase inhibitor drugs ?

Answer 22

allopurinol works for overproduction and underproduction

febuxostat

Question 23

what kind of clearance does allopurinol have ?

Answer 23

renal clearance

Question 24

what kind of clearance does febuxostat have ?

Answer 24

hepatic clearance

Question 25

which drug could be used if the patient has renal impairment ?

Answer 25

febuxostat because it has hepatic clearance

Question 26

what are the novel therapies available ?

Answer 26

uricosuric drugs recombinant uricase Urat-1 inhibitor IL-1 trap

Question 27

when can we use uricosuric drugs ?

Answer 27

patients with proper renal funnction

Question 28

what is the risk of using uricosuric drugs ?

Answer 28

renal calculi

Question 29

what do recombinant uricase drugs help inn n?

Answer 29

debulking tophi

Question 30

what is the disadvantage of using recombinant uricase ?

Answer 30

formation of neutralizing antibodies

Question 31

what other anti inflammatory drug can we use during an attack of gout ?

Answer 31

IL-1 trap

Question 32

which drug causes a drug-drug interaction with colchicine ?

Answer 32

clarithromycin or azithromycin

Question 33

what antibiotic can be suitable to avoid drug-drug interaction with colchicine if the patient is allergic to penicillin?

Answer 33

erythromycin due to risk of rhabdomyolysis

Question 34

what other calcium deposition disease can present with pseudo gout or pseudo arthiritis ?

Answer 34

calcium pyrophosphate dihydrate crystal deposition , which is more common in females

Question 35

where are the sites of deposition of CPD crytals ?

Answer 35

``` pubic symphysis knee wrist shoulders intervertebral space ```

Question 36

what do the crystals under light microscopy look like in pseudogout ?

Answer 36

clump of pyrophosphate crystals (rhomboid-shaped) in blood stained synovial fluid ( weakly bifringed)

Question 37

what are the radiological findings in pseudogout ?

Answer 37

calcified hyaline cartilage and fibrocartilage with linear and spotty appearance well preserved joint space

Question 38

what are the main precipitants of gout ?

Answer 38

acute illness trauma surgery alcohol starvation drugs