questions 8

Gout

Topic updated on 11/06/17 9:30am

Snapshot
  • A 55-year-old woman presents to the emergency department with acute pain in the left proximal interphalangeal (PIP) joint of the second digit. She reports that the pain is excruciating and has happened once a few years ago but self-resolved over the course of 2 weeks. She states that she recently increased her alcohol and red meat consumption and was recently started on hydrochlorothiazide. On physical exam the PIP joint is swollen, erythematous, warm, and tender to palpation. Preparations are made for an arthrocentesis to be performed. 
Introduction
  • Clinical definition
    • deposition of monosodium urate crystals leading to a crystal-induced arthropathy
  • Epidemiology
    • demographics
      • more common in men and the elderly
    • risk factors
      • conditions that increase serum urate levels (hyperuricemia)
  • Etiology
    • hyperuricemia 
      • defined as a serum urate level > 6.8 mg/dL
      • causes of hyperuricemia include
        • dietary habits
          • alcohol
          • red meat
          • seafood
        • medications
          • thiazide diuretics
          • loop diuretics
          • allopurinol
          • cyclosporine
          • low-dose aspirin
          • pyrazinamide
        • disorders of urate overproduction
          • hypoxanthine-guanine phosphoribosyltransferase (HPRT) deficiency
            • also known as Lesch-Nyhan syndrome
          • type I glycogen storage disease (Von Gierke disease)
          • tumor lysis syndrome
  • Pathogenesis
    • purine catabolism results in uric acid production
      • factors that influence serum uric acid level include
        • purine intake
        • purine synthesis
        • uric acid excretion by the kidneys and gut
    • conditions that increase the serum uric acid concentration increases the risk of crystal formation
      • deposition of uric acid crystals lead to an inflammatory response
        • resulting in a gout flare
  • Prognosis
    • acute attacks typically self-resolve
    • patients have an increased risk of recurrence
    • advanced gout and tophi may result without proper treatment
Presentation
  • Symptoms
    • acute gout
      • extreme pain of the affected joint (e.g., foot or ankle)
    • chronic tophaceous gout
      • stiff or swollen joint
      • deformity of the affected joint (e.g., nodules)
  • Physical exam
    • acute gout
      • typically mono-articular
        • e.g., involvement of the first metatarsophalangeal joint (podagra)
      • sudden onset of joint
        • tenderness
        • erythema and warmth
        • swelling
    • chronic tophaceous gout
      • subcutaneous nodules
      • typically non-tender
      • overlying skin can be taut
      • abnormal color
        • white or yellow deposits
Studies
  • Labs
    • hyperuricemia (> 6.8 mg/dL)
      • not sufficient for the diagnosis
      • the level may be lower during an attack
  • Synovial fluid analysis  
    • joint fluid aspiration and crystal analysis is the gold-standard
      • negatively birefringent needle-shaped crystals under polarized light 
        • yellow under parallel light and blue under perpendicular light
  • Making the diagnosis
    • demonstrating monosodium urate crystals in an affected joint via polarizing light microscopy
      • when this is not possible, the diagnosis can be clinically made
Differential
  • Septic arthritis 
    • a highly important differential diagnosis to exclude since this changes management 
    • distinguishing factors
      • a synovial fluid analysis will demonstrate
        • no crystals
        • > 50,000 cells/mcL
        • Gram stain may be positive
  • Pseudogout 
    • distinguishing factors
      • caused by deposition of calcium pyrophosphate crystals
      • crystal analysis will demonstrate weakly positive birefringent rhomboid crystals under polarized light
        • blue under parallel light
Treatment
  • Management approach
    • acute attacks can be managed with nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, or colchicine
      • acute gout attacks typically self-resolve in 1-2 weeks; however, treatment will hasten recovery
      • choice of treatment is dependent on certain patient factors (e.g., comorbidities, gout history, attack characteristics, availability, and cost)
    • preventing future attacks are managed by urate-lowering therapy
  • Conservative
    • lifestyle modification
      • indication
        • a preventative measure for patients with gout
      • examples
        • decrease alcohol, red meat, and seafood consumption
        • weight loss
        • discontinuing or modifying medication (e.g., changing their loop diuretic)
  • Medical  
    • medical management of acute attacks
      • NSAIDs 
        • indication
          • monotherapy agent for acute gout attacks
      • colchicine
        • indication
          • monotherapy agent for acute gout attacks
      • corticosteroids 
        • indication
          • monotherapy agent for acute gout attacks
    • medical management for preventing a future attack
      • urate-lowering therapy
        • indication
          • to prevent future attacks
        • medications
          • xanthine oxidase inhibitors (first-line)
            • e.g., allopurinol and febuxostat
          • uricosuric agents (second-line)
            • e.g., probenecid 
Complications
  • Recurrent flares
  • Tophi
  • Chronic gouty arthritis
  • Erosion or destruction of the joint


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Qbank (6 Questions)

TAG
(M3.RH.1) A 60-year-old man presents with pain and swelling in his great toe of three days duration. He has never had these symptoms before. On physical exam he is afebrile, and has erythema over the great toe. A clinical image is shown in Figure A. Which of the following laboratory or imaging results would confirm the diagnosis of acute gout in this patient? Topic Review Topic
FIGURES: A          

1. Elevated serum uric acid level
2. Radiographs showing joint space narrowing of the 1st metarsalphalangeal joint and soft tissue radio-densities
3. Magnetic-resonance imaging showing increased joint fluid and T2 signal intensity in the metatarsal head
4. Arthrocentesis showing intracellular crystals that are thin, needle-shaped, and strongly negatively birefringent
5. Arthrocentesis showing intracellular crystals that are rhomboid-shaped and weakly positively birefringent

PREFERRED RESPONSE ▶
TAG
(M3.RH.2) A 47-year-old male presents with pain and swelling in his great toe for three days duration. He has never had similar symptoms. He his afebrile, but has erthema and warmth over his great toe. A clinical image is shown in Figure A and a radiograph is shown in Figure B. Serum laboratory levels show a elevated uric acid level. The joint is aspirated, and crystal analysis is shown in Figure C. What is the most appropriate first line of treatment. Topic Review Topic
FIGURES: A   B   C      

1. Allopurinol
2. Colchicine
3. Indomethacin
4. Cephalosporin
5. Surgical irrigation and debridement

PREFERRED RESPONSE ▶
TAG
(M3.RH.5) A 67-year-old male active smoker with a history of gout, congestive heart failure (ejection fraction 35%), and moderate COPD is hospitalized for a CHF exacerbation. On the third day of his hospitalization, the patient has much improved from a respiratory stand-point but has developed a warm, painful right knee. Of note, the patient's home allopurinol was held during his hospitalization. Which of the following joint fluid analysis results would be most consistent with a diagnosis of recurrent gout? Topic Review Topic

1. Color: yellow; Clarity: clear; WBC: 700 (15% neutrophils); Bacteria: none
2. Color: straw Clarity: cloudy; WBC: 1000 (25% neutrophils); Bacteria: none
3. Color: straw; Clarity: clear; WBC: 2000 (30% neutrophils); Bacteria: none
4. Color: yellow; Clarity: cloudy; WBC: 20000 (70% neutrophils); Bacteria: none
5. Color: grey or bloody; Clarity: turbid; WBC: 90000 (90% neutrophils); Bacteria: many

PREFERRED RESPONSE ▶
TAG
(M3.RH.7) Following a weekend of binge drinking, an obese 45-year-old male presents with pain of acute onset in his right big toe. He notes that the pain started yesterday and has worsened significantly over the past 24 hours. This is the first time the patient has ever had such pain, however he notes that he is currently being treated for gastric ulcers. On exam, the first metatarsophalangeal joint is noticeably red and swollen. It is warm to the touch and light touch elicits severe pain. A joint aspiration reveals the presence of negatively birefringent, needle-shaped crystals. What is the most appropriate initial therapy for this patient? Topic Review Topic

1. Naproxen
2. Colchicine
3. Vancomycin
4. Allopurinol
5. Oral prednisone

PREFERRED RESPONSE ▶
TAG
(M3.RH.101) A 58-year-old male presents to the emergency department with rapid onset of severe pain and swelling in his right great toe overnight. He reports experiencing a similar episode several years ago but cannot recall the diagnosis or the medication he was given for treatment. His medical history is significant for hyperlipidemia, poorly controlled diabetes, and stage 3 chronic kidney disease. The patient's last documented GFR estimate 2 weeks ago was 32 mL/min/1.73m^2. The interphalangeal joint of the right great toe is aspirated, with the synovial fluid aspirate shown under polarized light microscopy in Figure A. Which of the following is the best management option for this patient? Topic Review Topic
FIGURES: A          

1. Initiate long-term colchicine therapy
2. Intrarticular glucocorticoid injection
3. Oral prednisone
4. Aspirin
5. Indomethacin

PREFERRED RESPONSE ▶
TAG
(M2.RH.86) A 55-year-old male presents to the emergency department with severe right knee pain. He states he woke last night with sharp, 10/10 non-radiating pain in his right knee. He denies recent trauma and states he had been previously healthy. He denies tobacco use and reports drinking a six-pack of beer on the weekends. Vital signs are T 38 C, HR 95 bpm, BP 140/90 mmHg, RR 18 bpm, SpO2 100%. Physical exam reveals an erythematous, edematous right knee that is exquisitely tender to palpation. Synovial fluid aspiration is performed and sent for analysis, which reveals 20,000 leukocytes/mm3, no organisms visualized, and is examined under polarized light (Figure A). Which of the following is the most likely diagnosis? Topic Review Topic
FIGURES: A          

1. Lyme arthritis
2. Septic arthritis
3. Pseudogout
4. Gout
5. Rheumatoid arthritis

PREFERRED RESPONSE ▶
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