Introduction A 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
QUESTIONS 1 of 9 1 2 3 4 5 6 7 8 9 Previous Next You have 100% on this question. Just skip this one for now. Take This Question Anyway (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: A B C Type & Select Correct Answer 1 Obtain an MRI of the knee 2% (96/5926) 2 Begin allopurinol therapy alone 11% (643/5926) 3 Begin empiric intravenous antibiotics 60% (3569/5926) 4 Give an intraarticular steroid injection 15% (881/5926) 5 Obtain a rheumatology consult 12% (710/5926) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 You have 100% on this question. Just skip this one for now. Take This Question Anyway (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: A Type & Select Correct Answer 1 Begin empiric antibiotics 1% (21/2007) 2 Begin oral NSAIDs 70% (1400/2007) 3 Begin treatment with allopurinol 17% (347/2007) 4 Emergent irrigation and debridement of the knee 3% (51/2007) 5 Obtain serum uric acid level 9% (171/2007) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (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: A Type & Select Correct Answer 1 Monosodium urate crystal deposition 88% (1719/1964) 2 Calcium pyrophosphate deposition 9% (185/1964) 3 Renal osteodystrophy 1% (28/1964) 4 Tuberculosis 1% (13/1964) 5 Sarcoidosis 1% (13/1964) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (OBQ04.265) Which of the following foot radiographs is most consistent with the diagnosis of gout? Review Topic | Tested Concept QID: 1370 FIGURES: A B C D E Type & Select Correct Answer 1 A 6% (72/1135) 2 B 81% (919/1135) 3 C 12% (131/1135) 4 D 0% (3/1135) 5 E 1% (7/1135) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2