Updated: 5/2/2020

Gout

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Review Topic
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Questions
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Evidence
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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)

(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 | Tested Concept

QID: 4891
FIGURES:
1

Obtain an MRI of the knee

2%

(98/6126)

2

Begin allopurinol therapy alone

11%

(654/6126)

3

Begin empiric intravenous antibiotics

61%

(3718/6126)

4

Give an intraarticular steroid injection

15%

(899/6126)

5

Obtain a rheumatology consult

12%

(730/6126)

L 3 B

Select Answer to see Preferred Response

(SBQ11OS.34.1) A 55-year-old male has severe knee pain and swelling for 2 days. He denies nausea, vomiting, fevers, or chills. On exam, the patient has an erythematous knee with a large effusion. He has pain with attempted range of motion. Radiographs are unremarkable. WBC, CRP, and ESR are within normal limits. The knee was aspirated and the WBC count was 20,000. A specimen from the aspirate is seen in Figure A. What is the next best step in treatment? Review Topic | Tested Concept

QID: 9108
FIGURES:
1

Begin empiric antibiotics

1%

(21/2133)

2

Begin oral NSAIDs

71%

(1507/2133)

3

Begin treatment with allopurinol

17%

(359/2133)

4

Emergent irrigation and debridement of the knee

2%

(53/2133)

5

Obtain serum uric acid level

8%

(176/2133)

L 2 C

Select Answer to see Preferred Response

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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 | Tested Concept

QID: 433
FIGURES:
1

Monosodium urate crystal deposition

88%

(1774/2027)

2

Calcium pyrophosphate deposition

9%

(188/2027)

3

Renal osteodystrophy

1%

(30/2027)

4

Tuberculosis

1%

(16/2027)

5

Sarcoidosis

1%

(13/2027)

L 2 B

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

QID: 1370
FIGURES:
1

A

7%

(81/1222)

2

B

81%

(987/1222)

3

C

11%

(140/1222)

4

D

0%

(4/1222)

5

E

1%

(7/1222)

L 2 D

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Topic COMMENTS (9)
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