Updated: 12/10/2017

Gout

Topic
Review Topic
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Questions
9
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Evidence
8
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Introduction
  • monosodium urate crystal deposition disorder
    • primary gout
      • an idiopathic disorder of nucleic acid metabolism that leads to hyperuricemia and deposition of monosodium urate crystals in joints (a purine breakdown product) 
    • secondary gout
      • is associated with a disease with high metabolic turnover (psoriasis, hemolytic anemia, leukemia, chemotherapy)
  • Epidemiology
    • demographics
      • recurrent attacks seen in men from ages 40-60 years
    • location
      • usually seen in lower limb
        • podagra (arthritis attacks of great toe) 
      • crystal deposition as tophi
        • ear helix, eyelid olecranon, Achilles tendon
    • risk factors
      • chemotherapy
  • Pathophysiology
    • dysfunctional nucleic acid metabolism causing hyperuricemia
    • deposition of monosodium urate crystals in synovium of joint
    • crystals lead to an inflammatory response activating
      • proteases
      • prostaglandins
      • leukotriene B4
      • free oxygen radicals
  • Associated conditions
    • renal stones
    • septic arthritis 
      • the presence of uric acid crystals does not exclude septic arthritis
Presentation
  • Symptoms
    • pain in joint
    • can resemble septic arthritis
    • symptoms of renal stones
  • Physical exam
    • may have decreased range of motion due to pain
    • white toothpaste-like appearance of tophus aspirate
Imaging
  • Radiographs
    • recommended views
      • AP and lateral of affected joint
    • findings
      • may see punched out periarticular erosion with sclerotic overhanging borders 
      • may see soft tissue crystal deposition (tophi) 
Studies
  • Labs
    • serum uric acid
      • elevated uric acid is not diagnostic (80% of people with an elevated uric acid will never have a gout attack)
  • Crystal analysis
    • diagnosis made by joint aspiration and crystal analysis
    • monosodium urate (MSU) crystals are
      • thin, tapered, needle-shaped intracellular crystals
        • yellow when aligned parallel to red compensator
        • blue when aligned across the direction of polarization
      • strongly negatively birefringent 
Treatment
  • Acute gout 
    • indomethacin vs. colchicine
      • indications
        • first line of treatment
      • medications
        • indomethacin (indocin) 50mg tid   
          • NSAID
          • inhibits phagocytosis
        • colchicine
          • indicated in acute attacks if patient has a history of peptic ulcers
          • inhibits inflammatory mediators
          • can be given intravenously 
    • oral, intraarticular or IV glucocorticoid
      • indication
        • patient unable to take NSAID or colchicine
  • Chronic gout
    • allopurinol
      • indications
        • first line of treatment for chronic gout attack
      • medications
        • allopurinol is an xanthine oxidase inhibitor
    • colchicine
      • indications
        •  for prophylaxis after recurrent attacks
        • up to 85% effective
 

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Questions (9)

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(OBQ13.256) A 65-year-old patient who recently underwent abdominal surgery for a diverticular abscess is referred for right knee pain and swelling for 2 days. Physical examination reveals a temperature of 38.3 degrees Celsius and heart rate of 105 bpm. A clinical photograph, results of synovial fluid analysis, and a polarizing microscopy image are seen in Figures A through C. Synovial fluid gram stain and cultures are pending. What is the most appropriate next step in management? Review Topic

QID: 4891
FIGURES:
1

Obtain an MRI of the knee

2%

(94/5799)

2

Begin allopurinol therapy alone

11%

(622/5799)

3

Begin empiric intravenous antibiotics

60%

(3506/5799)

4

Give an intraarticular steroid injection

15%

(856/5799)

5

Obtain a rheumatology consult

12%

(694/5799)

L 3

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(OBQ08.47) A 60-year-old man has had intermittent pain in his right great toe for the past 2 years. What is the most likely cause for the lesions shown in Figure A? Review Topic

QID: 433
FIGURES:
1

Monosodium urate crystal deposition

87%

(1677/1920)

2

Calcium pyrophosphate deposition

10%

(184/1920)

3

Renal osteodystrophy

1%

(28/1920)

4

Tuberculosis

1%

(12/1920)

5

Sarcoidosis

1%

(13/1920)

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(OBQ04.265) Which of the following foot radiographs is most consistent with the diagnosis of gout? Review Topic

QID: 1370
FIGURES:
1

A

6%

(60/1018)

2

B

82%

(837/1018)

3

C

11%

(110/1018)

4

D

0%

(3/1018)

5

E

0%

(5/1018)

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