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Updated: Feb 17 2022



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  • summary
    • Gout is a form of inflammatory arthritis caused by intraarticular monosodium urate crystal deposition that typically presents with recurrent acute exacerbation of joint swelling and severe pain.
    • Diagnosis is made by joint aspiration and crystal analysis showing strongly negatively birefringent needle-shaped intracellular crystals.
    • Treatment for acute gout attacks is NSAIDs with chronic gout being treated with allopurinol and medical management to reduce uric acid. 
  • Epidemiology
    • Demographics
      • recurrent attacks seen in men from ages 40-60 years
    • Anatomic 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
  • Etiology
    • Forms
      • 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)
    • 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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