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Clinical lectures: Yr1 > Gout and pseudogout > Flashcards

Gout and pseudogout Flashcards

epidemiology, pathophysiology, presentation, investigation, management and prognosis

1
Q

What is crystal arthropathy?

A

An inflammatory joint disorder resulting from deposition of crystals in the joint and surrounding soft tissues

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2
Q

What are the 2 types of crystal arthropathies?

A

Gout

Pseudogout/calcium pyrophosphate dihydrate (CPPD)

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3
Q

What is the difference between the crystals found in gout and pseudogout?

A

Gout is characterised by monosodium urate crystals

Pseudogout is characterised by calcium pyrophosphate crystals

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4
Q

What is the most common inflammatory arthritis in men over 40?

A

Gout

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5
Q

When in a women’s lifespan is gout most common?

A

Post-menopause

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6
Q

Why is gout most common in post-menopause stage then any other time in a woman’s life?

A

Oestrogen has an uricosuric effect (increases uric acid excretion)

Post-menopausal stage has decreased oestrogen levels, so excess uric acid isn’t excreted and builds up and crystallises

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7
Q

What is the prevalence of gout in individuals with comorbidities then prevalence of gout in individuals with no other conditions?

A

Gout is significantly more prevalent in individuals with comorbidities

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8
Q

Give 5 examples of common comorbidities of individuals with gout?

A

Hypertension, diabetes, CVD, Chronic Kidney Disease (CKD), obesity

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9
Q

Who amongst the ageing population is most likely to have severe gout attacks?

A

Individuals with medications to treat comorbidities

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10
Q

If an elderly individual takes diuretics to prevent heart failure, how can this increase the likelihood of gout attacks occuring?

A

Diuretics decrease uric acid excretion, so crystals can form

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11
Q

Is pseudogout more common in young or elderly populations?

A

Elderly populations, over 50 years old

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12
Q

What percentage of individuals aged 65-75 have pseudogout?

A

10-15%

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13
Q

What percentage of individuals aged over 85 have pseudogout?

A

30-60%

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14
Q

What condition does gout pathophysiology arise from, and define this condition?

A

Hyperuricaemia: abnormally high serum uric acid levels

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15
Q

What are the 2 types of uric acid production, and how can they cause hyperuicaemia?

A

Exogenous and endogenous uric acid overproduction can lead to build up of serum uric acid

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16
Q

What is exogenous uric acid production, and what type of purine precursor is used in the reaction?

A

Production of uric acid from exogenous purines, which are absorbed by body from consumed food

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17
Q

What is endogenous uric acid production, and what type of purine precursor is used in the reaction?

A

Production of uric acid from endogenous purines, which are made directly by body itself

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18
Q

How can high alcohol consumption/alcohol abuse cause hyperuricaemia?

A

Alcohol increases exogenous production of uric acid

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19
Q

What 2 groups of disorders increase endogenous production of uric acid, leading to hyperuricaemia?

A

Myeloproliferative

Lymphoproliferative

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20
Q

How can abnormal renal handling of urate result in hyperuricaemia?

A

Causes underexcretion of uric acid

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21
Q

What are 2 diseases that cause abnormal renal handling of urate?

A

Renal disease

Polycystic kidney disease

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22
Q

What percentage of individuals with hyperuricaemia/primary gout are underexcretors of uric acid?

A

90%

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23
Q

What are the 3 causes of hyperuricaemia that can result in gout?

A

Exogenous/endogenous overproduction of uric acid

Underexcretion of uric acid due to abnormal renal handling

Combination of overproduction and underexcretion of uric acid

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24
Q

Name 8 substances that cause hyperuricaemia (CANT LEAP)?

A

Cyclosporine
Alcohol
Nicotinic acid
Thiazides

Lasix (frusemide)
Ethambutol
Aspirin (low dose)
Pyrazinamide

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25
How is monosodium urate formed from uric acid in gout?
Uric acid ions combine with sodium ions to from monosodium urate (a common salt)
26
How are calcium pyrophosphate crystals formed in pseudogout?
Excess pyrophosphate complexes combine with calcium
27
What is the pathophysiology of pseudogout?
Calcium pyrophosphate crystals form in joint cartilage, then are shed into synovial fluid in synovium/joint lining
28
In gout and pseudogout, what triggers inflammation of the joint/synovium?
Build up of crystals
29
What is the volume of synovial fluid in a normal knee joint compared to in a gouty/pseudogouty knee joint?
less than 3.5 ml in normal knee joint More than 3.5 ml in gouty/pseudogouty knee joint
30
What is the viscosity of synovial fluid in a normal knee joint compared to in a gouty/pseudogouty knee joint?
Very high viscosity in normal knee joint Very low viscosity in gouty/pseudogouty knee joint
31
What is the colour of synovial fluid in a normal knee joint compared to in a gouty/pseudogouty knee joint?
Clear synovial fluid in normal knee joint Opaque, straw-coloured synovial fluid in gouty/pseudogouty knee joint
32
What is the WBC/mm3 of synovial fluid in a normal knee joint compared to in a gouty/pseudogouty knee joint?
200 mm3 in normal knee joint Over 100,000mm3 in gouty/pseudogouty knee joint
33
What is the percentage of neutrophils composing synovial fluid in a normal knee joint compared to in a gouty/pseudogouty knee joint?
Less than 25% in normal knee joint Over 50% in gouty/pseudogouty knee joint
34
What procedure is used to obtain a synovial fluid sample from a joint, and what are the steps?
Joint aspiration Insert needle into joint and remove synovial fluid, send culture to lab
35
Give 3 factors that can be tested from a synovial fluid sample obtained from joint aspiration of an individual with gout/pseudogout?
Infection, this is necessary to rule out as it can permanently destroy joint Inflammatory markers Crystals so that condition can be distinguished between pseudogout and gout
36
Give 6 examples of predisposing factors of gout?
Immediate postoperative period Alcohol abuse Local infection Stroke Large food intake high in purine Fasting
37
What are the 4 clinical phases of gout?
Asymptomatic hyperuricaemia Acute gout attack Intercritical gout Chronic tophaceous gout
38
What occurs in the asymptomatic hyperuricaemia phase of gout?
Serum uric acid level is elevated but there are no symptoms/signs of gout eg. no inflammation
39
How can acute gout attacks be described in terms of when they occur in the day, onset and how they affect the joint?
Often occur in early morning or night with rapid onset and makes joints red, hot, swollen, tender
40
Give 6 examples of joint commonly affected by acute gout attacks?
Ankle Wrist Hand Knee Big toe Other toes
41
Are acute gout attacks normally monoarticular or polyarticular?
Monoarticular
42
What percentage of acute gout attacks are polyarticular?
10-15%
43
In 50% of acute gout attack cases, what joint is initially affected?
1st metatarsophalangeal (MTP) joint (big toe)
44
What is podagra?
Acute gout attack of 1st metatarsophalangeal joint (big toe)
45
What is the intercritical gout phase?
Time between gout attacks where individual has no symptoms but monosodium urate crystals are still accumulating
46
What occurs in the chronic tophaceous gout phase?
Large, white, solid bumps of monosodium urate crystals form under skin and over joints, cartilage, bones
47
What is the difference in intercritical gout phases in acute gout and chronic gout?
In chronic gout, the intercritical gout phases are shorter (less time between attacks)
48
What are the 4 ways in which pseudogout can present?
Asymptomatic chondrocalcinosis Acute pseudogout Pseudo-OA/CPPD with OA Chronic pseudogout
49
How does asymptomatic chondrocalcinosis occur?
Accumulation of calcium crystals in joint cartilage
50
How is asymptomatic chondrocalcinosis diagnosed, and what joint does it normally affect?
Diagnosed as a radiographical imaging finding in asymptomatic pseudogout patients Mostly affects knee joint
51
How does pseudo-OA occur?
Pseudogout causes accelerated OA in joints not commonly affected by OA, such as MCP and elbow joints
52
Is pseudo-OA more common in men or women?
Women
53
What is the most common form of pseudogout when it presents as inflammatory?
Acute pseudogout
54
What is acute pseudogout?
Sudden, self-limiting monoarthritis (1 large joint) or olgioarthritis (2-4 large joints), that is the most common form of inflammatory pseudogout
55
How can you tell that there is joint inflammation in acute pseudogout?
Cardinal signs of inflammation
56
Do acute pseudogout attacks affect men or women more?
Men
57
What 7 joints are commonly affected by acute pseudogout?
Knee, wrist, shoulder, hip, ankle, elbow, toe
58
What 3 factors can trigger acute pseudogout attacks?
Trauma Surgery Severe medical illness
59
What is the difference between acute and chronic pseudogout, in terms of how many large joints are affected?
Acute is mono/oligoarthritic (1 or 2-4 large joints) Chronic is polyarthritic (5 or more large joints)
60
What 2 lab findings are used to diagnose gout?
Serum Uric acid is a negative acute phase reactant so has decreased level in gout attack, level should be re-checked 1-2 weeks after attack has settled and must be 360 micromol/L or more in remission period polarised light microscopy of synovial fluid shows negatively birefringent, needle-shaped crystals
61
How can urinalysis with a urine dipstick suggest gout?
hematuria
62
What lab finding is used to diagnose pseudogout?
Polarised light microscopy of aspirated synovial fluid shows positively birefringent rhomboid-shaped crystals
63
What are the 3 examples of lifestyle advice to give patients to manage gout?
Educating the patient to eat low-purine diet, less alcohol, lose weight to avoid obesity
64
Give 5 examples of high-purine food?
Shellfish eg. scallops, mussels alcohol red meat animal organs fish
65
Give 5 examples of medium-purine food?
Vegetables legumes lobster crab oyster
66
Give the main 2 ways of managing an acute gout attack?
Joint rest and ice Take a first-line drug
67
What are the 3 first-line drugs of acute gout attacks, and when is each drug used?
NSAIDs or COX II inhibitors are used first Oral colchicine used if NSAIDs or COX II inhibitors are contraindicated Local corticosteroid injection used if oral colchicine is contraindicated
68
What are the first and second line drug classes to manage intercritical gout?
First-line is xanthine oxidase inhibitors Second-line is uricosuric agents
69
What is the first-line drug used for intercritical gout, and what is its alternative drug?
Allopurinol, but febuxostat is an alternative drug is allopurinol isn't well-tolerated
70
Give 3 examples of uricosuric agents that are second-line drugs for intercritical gout?
probenecid, sulfinpyrazone, benzbromarone
71
Why is colchicine prophylaxis used with allopurinol to treat intercritical gout, and how long is it used for with allopurinol?
Colchicine prophylaxis used for first 3-6 months of allopurinol, as allopurinol increases chances of gout flare up in first few months of use
72
Give 3 side effects of allopurinol when used to treat intercritical gout?
Rashes, hepatotoxicity, hypersensitivity
73
What is a side effect of uricosuric agents when they are used to treat intercritical gout?
Increased risk of uric acid stone formation
74
Which 2 uricosuric agents are ineffective in treating intercritical gout when the individual has CKD?
Sulfinpyrazone and probenecid
75
What 3 antihypertensive drugs decrease chance of gout flares?
losartan, fenofibrate, atorvastatin
76
How is asymptomatic chondrocalcinosis treated?
It isn't treated as it usually settles itself
77
What are the 2 steps of managing acute pseudogout?
Joint aspiration Local corticosteroid injection
78
What 2 drugs can be used to manage chronic pseudogout?
NSAIDs, corticosteroids
79
To manage chronic pseudogout, what needs to be treated other than the pseudogout itself?
Associated diseases
80
Give examples of predisposing factors to pseudogout?
Aging Hyperparathyroidism Hemochromatosis Hypomagnesemia Hypophosphatasia May follow parathyroidectomy Acromegaly Hypothyroidism Trauma Infection Osteoarthritis
81
What stage of gout is associated with bone erosion?
Chronic tophaceous gout
82
Give 4 characteristic features of the bone erosion caused by chronic tophaceous gout?
Well defined erosion Sclerotic borders Overhanging edges No osteoporotic bone
83
What are 4 radiological findings that are associated with CPPD?
Triangular fibrocartilage calcification (calcification of stabilising joint at wrist) Subchondral sclerosis: hardening of bone below cartilage, common in load-bearing joints, common in OA Joint space narrowing Subchondral cyst formations
84
What are 6 differential diagnoses of gout?
RA OA PsA ReA Septic arthritis Pseudogout
85
What are the 6 differential diagnoses of pseudogout?
RA OA PsA ReA Septic arthritis Gout
86
How can pseudogout and gout be differentiated from RA?
RA has different degree of inflammation
87
How can pseudogout and gout be differentiated from septic arthritis?
Synovial fluid culture is tested for infectious agents that cause septic arthritis

Clinical lectures: Yr1 (28 decks)

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