Gout, Pseudogout, Ankylosing spondylitis, Reactive arthritis, Psoriatic arthritis Flashcards
(24 cards)
Gout overview
- Crystal Arthropathy
- Male > Female, usually age 30 & above
- comorbidities: OBESITY, metabolic syndrome, HTN, hyperlipidemia, glucose intolerance, CHF
- Due to hyperuricemia - either overproduction or underexcretion. Uric acid is excreted via the kidneys
- Decreased excretion of uric acid more common than increased production
- Initially one joint - First MTP is most common - known as Podagra
- More flares = more joints. Knees heels ankle, midfoot. Upper extremity involvement after many flares. Wrists, elbow and fingers.
- Disabling pain. Acute flare may be accompanied by fever, chills, malaise.
- May resemble cellulitis with surrounding cutaneous swelling and erythema.
Gout
Triggers
- Purine rich foods (alcohol, liver, seafood, yeasts) - Overconsumption of purines
- Kidney disease
- Trauma, surgery, starvation, fatty foods
- Medications (Thiazide & Loop diuretics (e.g. Hydrochlorothiazide), ACEI, Pyrazinamide Ethambutol, ASA, ARBs(except Losartan))
- PLATE Pyrazinamide, Loop diuretics, ACI & ARBs, & ASA, Thiazide, Ethambutol
Gout: hallmark sx and sx
- Symptoms may resolve quickly or without treatment in 1-2 weeks
- Monosodium Urate crystals are hallmark
- Urate crystals deposit in joints
- Tophi known as crystals deposition can present in ear helix, eyelids, joints, finger pads, tendons and bursae
Gout
Physical Exam
acute vs chronic
Acute:
- Severe joint pain
- Erythema, warmth, swelling
- Tenderness with decreased ROM
Chronic:
- Asymptomatic between attacks
- Tophi with longstanding disease
- Uric acid kidney stones
Gout
Diagnosis
- Lab tests: Serum urate >6 is diagnostic (measure when not on meds & 4 weeks after last attack. Levels may be normal during acute attack.
- Acute flare: CBC may show leukocytosis, ESR & CRP may be increased.
- Synovial fluid is definitive: Leukocyte count 5,000-80,000 (predominantly polymorphonuclear leukocytes). Monosodium Urate Crystals are: Negatively Bifringent Crystals! (Yellow under parallel light & blue under perpendicular light)
- Needle shaped crystals in synovial fluid may contain tophaceous material made of urate crystals.
- Radiographs: Bony erosions. Mouse or rat bite lesion. Tophi seen on MRI &/or CT later in disease.
gout comorbidities and def
Comorbidities associated with gout include metabolic syndrome, HTN, CAD, Hyperlipidemia, glucose intolerance, CHF and obesity.
*Presence of characteristic urate crystals in joint fluid, or
*A tophus proved to contain urate crystals by chemical means or polarized light microscopy, or
*The presence of 6 of the following 12 clinical, laboratory, and radiographic phenomena listed below:
*More than one attack of acute arthritis
*Maximal inflammation developed within 1 day
*Attack of monoarticular arthritis
*Joint redness observed
*First metatarsophalangeal joint painful or swollen
*Unilateral attack involving first metatarsophalangeal joint
*Unilateral attack involving tarsal joint
*Suspected tophus
*Hyperuricemia
*Symptomatic swelling within a joint (radiograph)
*Subcortical cysts without erosions (radiograph)
*Negative culture of joint fluids for microorganisms during attack of joint inflammation
gout tx
Treatment - acute 7-10 days
Non Steroidal Anti-inflammatory - NSAIDs (Indomethacin, Naproxen, Ibuprofen)
First line treatment 7-10 days**
Contraindicated in renal insufficiency, gastric and duodenal ulcers. Use with caution in those with cardiovascular disease.
Lifestyle modifications
Avoid alcohol
Maintain healthy weight
Control DM & HTN
Colchicine (2nd line)
Anti-inflammatory
Inhibits WBC migration
Use in those who cannot take NSAIDs or steroids*****
Avoid in elderly and renal insufficiency
Adverse effects- Nausea, abdominal pain, diarrhea
Treatment - acute
Glucocorticosteroids (3rd line)
Strongest class of anti-inflammatory
Intra-articular or oral.
Caution in diabetics
Used for both acute & chronic gout
Chronic Management 2-4 weeks
Allopurinol & Febuxostat - decrease uric acid
Macroscopic tophi
>3 attacks per year
Uric acid kidney stones
Significant hyperuricemia
Allopurinol = Xanthine oxidase inhibition ->decrease production of uric acid. Cannot be used with renal insufficiency
Febuxostat = nonpurine inhibitor of xanthine oxidase. Can be used in renal insufficiency. Increased risk of cardiovascular death.
Allopurinol is 1st line chronic tx. NOT USED FOR ACUTE ATTACKS
Uricosuric drugs (Probenecid & Sulfinpyrazone)
Increase uric acid excretion by the kidneys
Contraindicated with renal insufficiency
Pegloticase
Dissolves uric acid
Used in the treatment of refractory chronic gout
Calcium Pyrophosphate Deposition (CPPD) aka Pseudogout
Diagnosis and what to screen for
Radiographs - Crystal deposition in the fibrocartilage of the menisci = Chondrocalcinosis
Arthrocentesis - Positively bifringent, RHOMBOID-shaped calcium pyrophosphate crystals**
Blue under parallel light & Yellow under perpendicular light)
Screen for:
Hyperparathyroidism
Hypothyroidism
Hypomagnesemia
Hypophosphatasia
Hemochromatosis
gout: negatively bifringent - YELLOW UNDER PARALLEL and blue under perpendicular; NEEDLE SHAPED
Calcium Pyrophosphate Deposition (CPPD) aka Pseudogout overview
Crystal Arthropathy
Usually age >60
Ranges from asymptomatic to destructive arthritis
Mimics, RA, OA & Gout
Crystals are calcium pyrophosphate - calcium crystals initiate an inflammatory response via the immune system
CPPD attacks last longer than gout attacks despite treatment
Knee is most common
Calcium Pyrophosphate Deposition (CPPD) aka Pseudogout
Treatment
- Reduce inflammation - NSAIDs, colchicine, intra articular steroid injections.
- There are no analogous antihyperuricemics available for pseudogout.
- Colchicine -acute, chronic and prophylaxis
Reactive Arthritis aka Reiter’s Syndrome
- Rare autoimmune condition
- Inflammatory arthritis developing within days to weeks of gastrointestinal or genitourinary infection (Chlamydia trachomatis m.c.)
- Arthritis is reactive not septic. Usually unable to recover a specific organism from the joint.
- Positive HLA-B27 associated with increased incidence. Males 20-40 y.o.
- Seronegative → RF Negative
- Spondyloarthropathy → Autoimmune diseases that affect the joints
Human Leukocyte Antigen (HLA-B27)
- The HLA genes code for the proteins that help our body determine the difference between a foreign invader that needs to be attacked and what is ‘self’.
- HLA types also increase susceptibility to autoimmune diseases, where the body attacks its own cells.
Autoimmune diseases associated with being HLA B27 positive include:
* ankylosing spondylitis
* reactive arthritis
* psoriasis
* inflammatory bowel disease
* acute anterior uveitis (inflammation of the eye)
Reactive Arthritis aka Reiter’s Syndrome
Signs & symptoms
“Can’t pee, can’t see, can’t climb a tree.”
-VERY UNCOMMON
* Mono m.c. or oligoarthritis. Usually lower extremities. Knees m.c.
* Swelling warmth and tenderness of tendons (achilles, plantar fascia)
* Dactylitis - fusiform swelling of the finger or toe.
* Inflammatory low back pain
Reactive Arthritis aka Reiter’s Syndrome
Diagnosis and tx
Dx:
* No specific tests
* Arthrocentesis to r/o septic arthritis. Usually WBC increased but often <50,000. Negative cultures.
* Increased ESR & CRP
* Positive HLA-B27 provides prognostic information, but not diagnostic.
* Imaging is non-specific
Treatment: - Usually self-limiting
* NSAIDs first line.
* Low dose glucocorticosteroids.
* Disease Modifying Anti-Rheumatic Drugs (DMARDs) - Sulfasalazine or Methotrexate.
* Treatment of the underlying GI pathogen if caused by GI infection
* Patients with Chlamydia (doxycycline, azithromycin) or Gonorrhea (IM Ceftriaxone) infections should be be treated with the appropriate abx. Abx does not treat the arthritis.
Ankylosing Spondylitis
overview
- Ankylosis = joint stiffness due to fusion of the joints. Spondyl = vertebra. Itis = inflammation
- Hallmark of ankylosing spondylitis is inflammatory back pain and stiffness and sacroiliac pain.
- Males > Females, 15- 30 y.o., Positive HLA-B27, RF usually negative.
- Seronegative → RF Negative Spondyloarthropathy → Autoimmune diseases that affect the joints
- Chronic inflammation of intervertebral discs and facet joints due to autoimmune process.
- No specific antibody
Ankylosing Spondylitis
Treatment
- Physical therapy and exercise program is highly effective & recommended.
- NSAIDs -first line. May slow radiographic progression***
- Intra articular Glucocorticosteroid injection into SI joint. Oral not recommended.
- TNF Inhibitors - 2nd line. All are sub-q or IV. Etanercept, Adalimumab, Infliximab, certolizumab pegol, golimumab.
Ankylosing Spondylitis
Signs & Symptoms
- Onset is usually gradual with intermittent periods of diffuse low back pain, stiffness and decreased ROM.
- Pain is worse at night and in morning.
- Pain is relieved with exercise and physical activity.
- Systemic inflammatory disease - weight loss, fever, fatigue.
- Sacroiliitis & Arthritis of larger joints.
- Enthesopathy - Pain at achilles tendon insertion and/or plantar fascia, Greater trochanter, epicondyles.
- Dactylitis (2-6%)- uniform swelling of the fingers and toes (sausage digits.
- Extra articular - uveitis (acute & unilateral), heart disease, pulmonary fibrosis, aortitis, decreased chest expansion.
- Skin Psoriasis in about 10%.
- IBD in about 5-8%
*
Ankylosing Spondylitis Diagnosis
- Labs - Increased ESR & CRP, Positive HLA-B27**, Negative Rheumatoid factor (RF) & Antinuclear Antibody (ANA)
- Radiographs & MRI
- Sacroiliac joints-sacroiliitis (erosions, sclerosis and ankylosis.
- Ap/Lateral of lumbar spine: BAMBOO SPINE - Straightening of spine with squaring & fusion of vertebrae**
- Bridging syndesmophytes classic & late x-ray finding.
- MRI - most sensitive. Confirms the presence of sacroiliitis and defines the extent of inflammation and structural changes.
Psoriatic
Psoriatic Arthritis overview
- Chronic immune mediated disease that results in inflammatory arthritis in patients with psoriasis affecting the skin & joints.
- Seronegative spondyloarthropathy (No specific autoantibody)
- Affects approximately 5-20% of patients with psoriasis.
- Male to Female ratio 1:1. 30-55 years of age.
- Psoriasis precedes the onset in 80% of patients.
- High Rate of heritability
Psoriatic Arthritis Signs & Symptoms
- Asymmetric inflammatory oligoarthritis. May be symmetric in distal arthritis. Unlike RA psoriatic arthritis involves the DIP joint.
- Psoriasis- Erythematous plaques with thick silvery-white scales & pitting of the nails*****
- Dactylitis- “sausage digits”- uniform swelling of fingers or toes.
- Sacroiliitis & spondylitis- LBP, neck pain, thigh and hip pain.
- Enthesitis- Achilles, medial & lateral epicondylitis, plantar fasciitis.
- Uveitis & conjunctivitis
Psoriatic Arthritis
Diagnosis
Labs
- No specific diagnostic test
- Patterns vary over time, complicating the diagnosis.
- Worsens over time.
- No diagnostic tests for PsA.
- CRP & ESR may be elevated.
- Usually do not have rheumatoid factor or anti-CCP antibodies.
- Approximately 25% of patients are HLA-B27 positive.
- Radiographic findings: X-rays are best initial test. “Pencil in a cup” deformities
- 5 Subtypes: dont need to know
- Asymmetric oligoarthritis of hands & feet. <5 joints
- Symmetric polyarthritis - resembles RA. >5 joints
- DIP joint predominant pattern
- Axial involvement
- Arthritis mutilans - rarest form
Psoriatic Arthritis
Considerations & Differentials - should you aspirate through a psoriatic plaque?
- When acute onset can mimic crystal arthropathies (gout & pseudogout). Keep in mind if joint aspiration is required.
- Do not aspirate through a psoriatic plaque! -Increased risk of seeding bacteria****
- Differential includes other forms of inflammatory arthritis including RA.
- Bony destruction is irreversible - Prompt diagnosis helps preserve mobility, function and quality of life.
Psoriatic Arthritis
Treatment - mild vs mod vs severe
Mild Disease:
- NSAIDs -1st line for mild oligoarticular arthritis (<5 joints) with no joint damage on x-ray
Moderate Disease:
- Classic DMARDs if persistent joint inflammation despite NSAIDs. Methotrexate preferred over sulfasalazine. Methotrexate is teratogenic. Patients cannot get pregnant. Most efficacious for skin findings. Leflunomide affects T cell pathway. Good for peripheral synovitis & dactylitis but minimal effect on skin.
Severe:
- TNF inhibitors or other biologic DMARDs reserved for severe disease with functional limitations. Strongly effective for enthesitis, dactylitis and axial disease.
- Topical agents to help psoriatic skin plaques
- Surgery - Joint replacement or stabilization. Reserved for long-standing erosive, destructive and uncontrolled disease.
xray:
pencil in a cup
mouse and rat bite
bamboo spine
chondrocalcinosis
pencil in a cup - psoriatic
mouse and rat bite - gout
bamboo spine - ankylosing spondylitis
chondrocalcinosis - pseudogout
