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57 Cards in this Set
- Front
- Back
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What causes symptoms of gout?
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Deposition of monosodium urate (MSU) crystals in and around the tissues of joints.
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Classic gout passes through what 3 stages?
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asymptomatic hyperuricemia
acute intermittent gout advanced gout |
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What level of uric acid is considered hyperuricemia?
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Men >7 mg/dL
Women >6 mg/dL |
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In men when do uric acid values reach peak levels?
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Value increases dramatically around the time of puberty to reach the level that will be maintained in adulthood.
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In women when do uric acid values reach peak levels?
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Gradually increase hrough early adulthood and reach peak level after menopause.
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True or False:
Most people with hyperuricemia develop gouty arthritis. |
False!
Most never develop any symptoms of gout |
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What are symptoms of a gouty attack?
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warmth, swelling, erythema, and pain in affected joint.
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What is the most common joint affected in an initial gout attack?
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Usually monoarticular in the First metatarsophalangeal joint
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What are systemic symptoms that may be seen in acute gout?
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fever, chills, malaise
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The period of time between acute gout attacks when the joint is free of symptoms is called what?
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Intercritical period
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Advanced gout usually develops after how many years of acute intermittent gout?
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10 or more years.
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What distinguishes acute intermittent gout from advanced gout?
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The intercritical periods are no longer free of pain. Involved joints are persistently uncomfortable and swollen
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True or False
Gouty attacks do not occur in advanced gout |
False
Attacks continue to occur and may become more frequent. |
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What are tophi?
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deposits of monosodium urate crystals that form nodules in or around joints or under the skin.
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What factors are associated with the formation of tophi?
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early age of gout onset
long periods of active, untreated gout average of four attacks per year upperextremity gout polyarticular gout |
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Where do tophi most often form?
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fingers, wrists, ears, knees olecranon bursa, ulnar aspect of forearm, achilles tendon
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What are organs that may be affected by tophi?
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kidney: renal pyramids
heart: valves eyes: sclerae |
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What are examples of triggering mechanisms for gout?
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trauma (even as minor as a long walk)
alcohol ingestion drugs |
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How does alcohol consumption trigger gout?
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accelerates the breakdown of intracellular ATP resulting in an increase in uric acid levels.
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In addition to the alcohol content, beer has this added impact on uric acid levels
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contains large quantities of guanosine which is catabolized to uric acid.
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What effect do Thiazide diuretics have on uric acid levels?
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They selectively interfere with urate excretion which raises the plasma level of uric acid
(decrease excretion) |
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What drug that is used to treat gout can actually make symptoms worse during initial treatment? Why?
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Allopurinol, when the urate concentration of the synovial fluid changes rapidly microtophi are destabilized. As they break apart crystals are shed into the synovial fluid.
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What are the three forms of hyperuricemia-induced renal disease?
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chronic urate nephropathy
acute uric acid nephropathy uric acid nephrolithiasis |
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What causes chronic urate nephropathy?
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deposition of MSU crystals in the renal mudulla and pyramids.
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What is acute tumor lysis syndrome?
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chemotherapy given for lymphomas and leukemias can liberate purines during cell lysis. Uric acid precipitates in the kidney causing acute renal failure.
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Diseases associated with overproduction of urate in children and young adults are
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enzymatic defects in purine pathway
glycogen storage diseases hematologic disorders |
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Diseases associated with under excretion of uric acid in children and young adults
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familial juvenile hyperuricemic nephropathy
polycystic kidney disease chronic lead intoxication medullary cystic desease focal tubulointerstitial disease |
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Hyperuricemia is common in transplant patients due to what immunosuppressive drug?
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cyclosporine
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Cyclosporine induced hyperuricemia differs from primary hyperuricemia in what 3 ways?
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progresses to gout in 1/6 vs 1/30 patients
asymptomatic stage is markedly shortened tophi appear rapidly. |
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The rare woman with premenopausal gout and normal renal function should be evaluated for what genetic diseases?
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familial juvenile hyperuricemic nephropathy
inborn error of purine metabolism |
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What articular conditions can mimic gout?
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Other crystalline arthropathies (CPPD, apatite, liquid lipid)
infection, sarcoidosis, trauma |
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What lab test can definitively diagnose gout?
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crystal analysis of synovial fluid from the inflamed joint or tophaceous material showing MSU crystals.
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True or False
During an acute attack of gout the serum uric acid may be normal. |
True
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True or False
An acute attack is always the first symptom of gout. |
False
40% of patients present with symptoms of renal stones |
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What are factors that affect the solubility of urate in the plasma?
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temperature, pH, cation concentration, articular hydration state, presence of nucleating agents around which urates may coalesce
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What is one factor that may explain the predilection of gout for the big toe?
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The temperature is generally lower at this peripheral site.
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What is one factor that may explain common onset of an acute attack of gout at night?
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intraarticular dehydration during the night.
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What are the 4 categories of CPPD deposition?
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hereditary
sporadic/idiopathic metabolic abnormality post-traumatic |
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What are the five clinical presentations associated with articular CPPD?
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pseudogout
pseudo-osteoarthritis pseudo-rheumatoid arthritis pseudo-neruopathic arthropaty lanthanic |
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What are major causes of hyperuricemia due to underexcretion?
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renal insufficiency
medications ethanol and organic acids lead nephropathy |
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What are major causes of hyperuricemia due to overproduction?
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high cell turnover
high purine diet, ethanol genetic causes |
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Is most hyperuricemia due to overproduction or underexcretion?
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underexcretion 90%
overproduction 10% |
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How can you distinguish between overproducers and underexcreters of uric acid?
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24 hr urine collection
>800 mg/24hrs = overproducer <800 mg/24hrs =underexcreter random urine uric acid may also be used, but is not as accurate. |
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What is the peak age of onset of gout?
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men 40-50
women 60 and older |
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How are MSU crystals distinguished from CPPD crystals under polarized light?
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MSU do not show birefringence
CPPD do |
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What are the 3 categories of drugs that can be used to treat an acute attack of gout?
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Colchicine
NSAIDS Steroids |
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What are some indications for the use of uric acid lowering agents?
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>2 attacks within 2 years
renal stones (urate or calcium) tophaceous gout chronic gouty arthritis with erosive disease hyperuricemia >12 mg/dL or 24 hr urinary excretion >1100 mg |
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What are predisposing conditions to Calcium Pyrophosphate Dihydrate deposition disease
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hemochromatosis
hyperparathyroidism hypomagnesemia hypophosphatasia increasing age |
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What attack can be provoked by pamidronate, G-CSF, intraarticular hyaluronic acid, joint lavage or surgery?
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pseudogout
(results from deposition of Calcium pyrophosphate dihydrate-- CPPD) |
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What is chondrocalcinosis?
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refers to the characteristic radiographic features of CPPD deposition in articular cartilage
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What are the differences between gout and pseudogout attacks?
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pseudogout attacks take longer to reach peak intensity, attacks may last longer, and it is more common in larger joints with the knee being the most common.
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CPPD crystals are most commonly found in this type of tissue.
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cartilage
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These radiographs are used to screen patients for CPPD deposits
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AP view of both knees
AP view of pelvis PA view of each hand including wrists. |
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Basic Calcium Phosphate crystals can be found in synovial fluid, but is not detected by polarized light microscopy. Why?
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The crystals are too small to be seen unless they are in very large aggregates.
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What syndrome is characterized by large, noninflammatory effusion, severe radiographic damage and large rotator cuff tears, and is seen predominantly in elderly women?
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Large Joint Destructive arthritis/Milwaukee shoulder syndrome
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Oxalate crystals have been observed in the joints of patients with this condition.
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Overt renal failure.
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What is calcinosis
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the soft tissue deposition of BCP (basic calcium phosphate) crystals.
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