Lecture 98 - Gout and other mineral deposits

Question 1

what is gout

what is the precursor

Answer 1

chronic inflammatory arthritis that results from monosodium urate (MSU) crystal deposition in tissues or joints resulting from supersaturation of uric acid in extracellular fluids

Precursor: Hyperuricemia –

Question 2

what is gout

what is the precursor

Answer 2

chronic inflammatory arthritis that results from monosodium urate (MSU) crystal deposition in tissues or joints resulting from supersaturation of uric acid in extracellular fluids

Precursor: Hyperuricemia –

Question 3

Causes of hyerpuricemia:

Answer 3

Decreased Uric Acid Excretion through the kidey

Increased Uric Acid Production

Question 4

what can lead to increased uric acid production

Answer 4

Tumor lysis syndrome, Luekmia, myeloproliferation

Lesch Nyan Syndrome

Question 5

Risk factors for Gout:

modifiable (drugs, lifetyle, Comorbidities)
non modifiable

Answer 5

Age – older men
Meds – Thiazides, furosemide, low dose ASA, Cyclsporin

Life style –obesity,, high meat diet, binge drinking

Comorbdities – HTN, CVD, DM, CKD, HLD

Question 6

Per lecture – describe the pathogenesis of gout

Answer 6

Uric Acid Burden - Super saturation –> Crystals –> Deposition into tissues –> Bound by Antibodies + Phagocytosis of PMNs –> Inflammatory Mediators (IL-1, IL-6, TNF) –> ROS, Complemen t

The inflammasome

Question 7

what are the 4 stages of gout

Answer 7

asymptomatic hyperuricemia

Acute intermittent Gout – acute flair – Rapid onset and monoarticular

Inter-critical gout – asymptomatic between flaires, but uric acid crystals still present in the joint –> chronic low grade inflammation –>high risk of attacks and thopi

advanced gout – lng standing gout; intercritical periods are no long pain free

Question 8

eval of synovial fluid under polarized light =

what other tests of the synovial fluid should be run to rule out disease proceses

Answer 8

Intracelluar Needle Shaped Rods with Negative Biferengence under polarized light (yellow under parallel light, blue under perpendicular)

– also do gram stain to check for prescence of bacteria;
DDx - septic arthritis

Question 9

classical radiographic finding of advanced gout

Answer 9

Rat bite

Question 10

Clinical manifestations of gout

Answer 10

Gouty Arthritis – recurrent attacks of articular and periarticular inflammation
Tophus – Accumulation of MSU deposits in joints, bones, soft tissue
Gout Nephrolithiasis – uric acid calculi
Gout Nephropathy –

Question 11

what drugs/exposures also known to cause gout

Answer 11

Cyclosporin– can interfere with uric acid exceretion

Lead Poisoning
Moonshine /
Occupational – Painter, Plumber, Pipefitters, mechanics, battery, steel workers

Question 12

what is the goal level of uric acid in the serum?

Question 13

treatments for acute gout

Answer 13

NSAIDs – first line for attacks,
Colchicine
Il-1RA = Anakinra (Kineret)

Question 14

treatment for chronic gout

Answer 14

Colchicine
Allopurinol
Febuxostat
Probenacid

Question 15

Mechanism of Colchicine

Answer 15

Microtubulin formation inhibition

Question 16

mechanism of allopurinol and febuxostat

contraindicated with what drugs

side effects of each

Answer 16

Xanthine Oxidase inhibitin – prevents formation of Uric acid

ccontraindicated with Azathriprine and 6MP which require XO for metabolsim

Allopurinol –
DRESS SYNDROME – Drug Rxn, Eosino, Systemic Symptoms
Hypersensitivity, Steven Johnson Syndrome,

Febuxostat – Hepatic impairment

Question 17

maintenacne therapy for Gout

what is the mechanism

Answer 17

Pegloticase –

Facilitates the conversion of Uric acid to Allantoin (water soluble and renally excreted)

Question 18

what joint is classically affected with Gout

Answer 18

MTP of the big toe – (podagra)

Question 19

what is pseudogout

Answer 19

Calcium Pyrophosphate Dihydrate Deposition Disease (CPPD)

Question 20

what is pseudogout

what joints are affected?

what is seen under polarized light

what might been seen on imaging?

Treatment:

Answer 20

Calcium Pyrophosphate Dihydrate Deposition Disease (CPPD)

Joints – Knee, Wrist, Pubis, hip,

Polarized light: weakly birefringement (blue when parallel); rhomboid shaped

Imaging: chondrocalcinosis

Treat: NSAIDs, colchicine, STeroids

Question 21

Milwaukee Shoulder Syndrome –

what is the crystal deposition?
who does it effect?
what is seen on imaging?

Answer 21

deposition of Hydroxyapatite Crystals leading to activation of enzymse that lead to joint destruction

women of 5th-6th decade

XR erosion of humoral head, cartilage, capsule, bursae

Question 22

Causes of hyerpuricemia:

Answer 22

Decreased Uric Acid Excretion through the kidey

Increased Uric Acid Production

Question 23

what can lead to increased uric acid production

Answer 23

Tumor lysis syndrome, Luekmia, myeloproliferation

Lesch Nyan Syndrome

Question 24

Risk factors for Gout:

modifiable (drugs, lifetyle, Comorbidities)
non modifiable

Answer 24

Age – older men
Meds – Thiazides, furosemide, low dose ASA, Cyclsporin

Life style –obesity,, high meat diet, binge drinking

Comorbdities – HTN, CVD, DM, CKD, HLD

Question 25

Per lecture -- describe the pathogenesis of gout

Answer 25

Uric Acid Burden - Super saturation --> Crystals --> Deposition into tissues --> Bound by Antibodies + Phagocytosis of PMNs --> Inflammatory Mediators (IL-1, IL-6, TNF) --> ROS, Complemen t The inflammasome

Question 26

what are the 4 stages of gout

Answer 26

asymptomatic hyperuricemia Acute intermittent Gout -- acute flair -- Rapid onset and monoarticular Inter-critical gout -- asymptomatic between flaires, but uric acid crystals still present in the joint --> chronic low grade inflammation -->high risk of attacks and thopi advanced gout -- lng standing gout; intercritical periods are no long pain free

Question 27

eval of synovial fluid under polarized light = what other tests of the synovial fluid should be run to rule out disease proceses

Answer 27

Intracelluar Needle Shaped Rods with Negative Biferengence under polarized light (yellow under parallel light, blue under perpendicular) -- also do gram stain to check for prescence of bacteria; DDx - septic arthritis

Question 28

classical radiographic finding of advanced gout

Answer 28

Rat bite

Question 29

Clinical manifestations of gout

Answer 29

Gouty Arthritis -- recurrent attacks of articular and periarticular inflammation Tophus -- Accumulation of MSU deposits in joints, bones, soft tissue Gout Nephrolithiasis -- uric acid calculi Gout Nephropathy --

Question 30

what drugs/exposures also known to cause gout

Answer 30

Cyclosporin-- can interfere with uric acid exceretion Lead Poisoning Moonshine / Occupational -- Painter, Plumber, Pipefitters, mechanics, battery, steel workers

Question 31

what is the goal level of uric acid in the serum?

Answer 31

goal level is

Question 32

treatments for acute gout

Answer 32

NSAIDs -- first line for attacks, Colchicine Il-1RA = Anakinra (Kineret)

Question 33

treatment for chronic gout

Answer 33

Colchicine Allopurinol Febuxostat Probenacid

Question 34

Mechanism of Colchicine

Answer 34

Microtubulin formation inhibition

Question 35

mechanism of allopurinol and febuxostat contraindicated with what drugs side effects of each

Answer 35

Xanthine Oxidase inhibitin -- prevents formation of Uric acid ccontraindicated with Azathriprine and 6MP which require XO for metabolsim Allopurinol -- DRESS SYNDROME -- Drug Rxn, Eosino, Systemic Symptoms Hypersensitivity, Steven Johnson Syndrome, Febuxostat -- Hepatic impairment

Question 36

maintenacne therapy for Gout | what is the mechanism

Answer 36

Pegloticase -- | Facilitates the conversion of Uric acid to Allantoin (water soluble and renally excreted)

Question 37

what joint is classically affected with Gout

Answer 37

MTP of the big toe -- (podagra)

Question 38

what is pseudogout

Answer 38

Calcium Pyrophosphate Dihydrate Deposition Disease (CPPD)

Question 39

what is pseudogout what joints are affected? what is seen under polarized light what might been seen on imaging? Treatment:

Answer 39

Calcium Pyrophosphate Dihydrate Deposition Disease (CPPD) Joints -- Knee, Wrist, Pubis, hip, Polarized light: weakly birefringement (blue when parallel); rhomboid shaped Imaging: chondrocalcinosis Treat: NSAIDs, colchicine, STeroids

Question 40

Milwaukee Shoulder Syndrome -- what is the crystal deposition? who does it effect? what is seen on imaging?

Answer 40

deposition of Hydroxyapatite Crystals leading to activation of enzymse that lead to joint destruction women of 5th-6th decade XR erosion of humoral head, cartilage, capsule, bursae