S2: Ch 6 Connective Tissue 1-6

Front 1

158. What is gout caused by and what is the hallmark of the disease?

Back 1

a. Gout is an inflammatory monoarticular arthritis caused by crystallization of monosodium urate and joints
b. Hyperuricemia is a hallmark of the disease, but it does not by itself indicate gout

Front 2

159. Who is primarily affected by gout?

Back 2

a. 90% of patients are men over 30 years of age.
b. Women are not affected until after menopause

Front 3

160. Pathogenesis of gout?

Back 3

a. Either increased production of uric acid or decreased excretion of uric acid.
b. Decreased excretion of uric acid accounts for 90% of all cases!!!

Front 4

161. What three conditions lead to increased production of uric acid?

Back 4

a. Lesch-nyhan syndrome
b. Phosphoribosyl pyrophosphate synthetase overactivity.
c. Increase cell turnover associated with the number of conditions, including:
1. Cancer chemotherapy
2. Chronic hemolysis
3. Hematologic malignancies

Front 5

162. 3 causes of decreased excretion of uric acid?

Back 5

1. Renal disease
2. NSAIDs and diuretics
3. Acidosis

Front 6

163. What is Lesch-Nyhan syndrome caused by?

Back 6

a. Deficiency of hypoxanthine-guanine phosphoribosyltransferase.

Front 7

164. Pathophysiology of inflammation in gout?

Back 7

a. PMNs play a key role in the acute inflammation of gout.
b. It's develops when uric acid crystals collect the synovial fluid in the extracellular fluid become saturated with uric acid
c. IgGs coat monosodium urate crystals, which are phagocytosed by PMN, leading to release of inflammatory mediators and proteolytic enzymes from PMNs
d. This then results in inflammation.

Front 8

165. Precipitants of an acute gouty attack?

Back 8

1. ↓’d temperature
2. Dehydration
3. Stress (emotional or physical)
4. Excessive alcohol intake
5. Starvation

Front 9

166. 4 stages of Gout?

Back 9

1. Asymptomatic hyperuricemia
2. Acute gouty arthritis
3. Intercritical gout
4. Chronic tophaceous gout.

Front 10

167. Asymptomatic hyperuricemia?

Back 10

a. Increased serum uric acid level in absence of clinical findings of gout.
b. May be present without symptoms for 10 to 20 years.
c. Should not be treated because over 95% of patients remain asymptomatic

Front 11

168. Acute Gouty Arthritis peak age of onset?

Back 11

a. 40 to 60 years of age for men.

Front 12

169. Presentation of acute gouty arthritis?

Back 12

a. Initial attack usually involves one joint of the lower extremity
1. sudden onset of exquisite pain- patient may be unable to tolerate a bedsheet on effected joint. Pain often awakens the patient from sleep.
2. Most often affects the big toe- the first metatarsophalangeal joint (Podagra). Other common joints affected are ankles and knees.

Front 13

170. Other features of Acute Gouty Arthritis?

Back 13

a. Pain and cytolytic changes- erythema, swelling, tenderness, and warmth
b. Fever may or may not be present
c. As resolves the patient may have desquamation of overlying skin.

Front 14

171. Intercritical gout?

Back 14

a. An asymptomatic period after the initial attack.
b. The patient may not have another attack for years
c. 60% of patients have a recurrence within one year. Some patients (fewer than 10%) never have another attack of gout.
d. There is a 75% likelihood of a second attack within the first two years.
e. Attacks tend to become polyarticular with increased severity over time.

Front 15

172. Chronic tophaceous gout?

Back 15

a. Occurs in people who have had poorly controlled gout for more than 10-20 yrs.
b. Will See Tophi!!!
c. Common locations of tophi:
1. Extensor surfaces of forearms
2. Elbows
3. Knees
4. Achilles tendons
5. Pinna of external ear.

Front 16

173. Tophi?

Back 16

a. Aggregations of urate crystals surrounded by giant cells in an inflammatory reaction
b. Seen only after several weeks of acute gout; noted after an average of 10 yrs following an initial attack.
c. Tophi cause deformity and destruction of hard and soft tissues.
d. In joints, they lead to destruction of cartilage and bone, triggering secondary degeneration and development of arthritis.
e. They may be extra-articular.

Front 17

174. Diagnosis of Gout?

Back 17

a. Joint aspiration and synovial fluid analysis (under a polarizing microscope) is the only way to make a definitive diagnosis.
b. Needle-shaped and negatively birefringent urate crystals appear in synovial fluid!!!
c. Serum uric acid is NOT helpful in diagnosis bc it can be normal even during an acute gouty attack.
d. Radiographs reveal punched-out erosions w/an overhanging rim of cortical bone.

Front 18

175. How long does an acute gouty attack typically last if untreated?

Back 18

a. 7-10 days and then resolves.
b. Severe episodes last longer.

Front 19

176. Note: with Gout, do a gram stain and culture of the synovial fluid to r/o septic arthritis, which is the most worrisome dx on the differential list.

Back 19

176. Note: with Gout, do a gram stain and culture of the synovial fluid to r/o septic arthritis, which is the most worrisome dx on the differential list.

Front 20

177. Complications of gout?

Back 20

a. Nephrolithiasis- risk is small (< 1%/yr)
b. Degenerative arthritis occurs in < 15% of pts.
c. Incidence is decreasing due to effective tx of hyperuricemia and consequent prevention of tophaceous gout.

Front 21

178. What should be done to avoid 2° causes of hyperuricemia in the tx of gout

Back 21

a. Avoid Meds that increase uric acid levels (thiazides and loop diuretics).
b. Obesity
c. Reduce alcohol intake
d. Reduce dietary purine intake

Front 22

179. Tx of Acute Gout?

Back 22

a. Bed rest is important. Early ambulation may precipitate a recurrence.
b. NSAIDS
c. Colchicine
d. Steroids

Front 23

180. Treatment of choice for acute gout?

Back 23

a. NSAIDS.
b. Indomethacin is traditionally used, but other NSAIDs are effective.

Front 24

181. Value of Indomethacin for acute gout?

Back 24

a. Very effective in relieving pain promptly; best if initiated early- a delay in initiating therapy can impair response.

Front 25

182. Use of Colchicine for Acute gout?

Back 25

a. An alternative for pts who cannot take NSAIDs or did not respond to NSAIDs.
b. Effective but less favoured bc 80% of treated pts develop significant N/V, abdominal cramps, and severe diarrhea.
c. Compliance tends to be low due to these side effects.

Front 26

183. In whom is colchicine contraindicated?

Back 26

a. Renal insufficiency
b. Cytopenia

Front 27

184. Utility of Steroids for acute gout?

Back 27

a. Oral Prednisone (7-10 day course) if pt does not respond to or cannot tolerate NSAIDs of colchicine.
b. Intra-articular steroid injections (if only 1 joint is involved) - dramatic relief of symptoms.

Front 28

185. When should gout prophylaxis be initiated?

Back 28

a. Wait until pt has had at least 2 acute gouty attacks (or perhaps 3) before initiating prophylactic therapy.
b. 2 attacks per year is sometimes used as a rough guideline.
i. This is bc the second attack may take years to occur (if at all), and so the risk-to-benefit ratio for prophylactic medication (allopurinol or uricosuric agents) is not favourable after one gouty attack.

Front 29

186. How should gout prophylaxis be administered?

Back 29

a. When giving prophylaxis (either allopurinol or a uricosuric agent (Probenecid, sulfinpyrazone) add either colchicine or NSAID for 3-6 months to prevent an acute attack.
b. The colchicine or NSAID can then be discontinued, and the patient can remain on the uricosuric agent or allopurinol indefinitely.