Gout

Gout

Gout is defined as a peripheral arthritis resulting from the deposition of sodium urate crystals in one or more joints.

Gout
Gout encompasses a group of disorders that occur alone or in combination and include (1) hyperuricemia, (2) attacks of acute, typically monarticular, inflammatory arthritis, (3) tophaceous deposition of urate crystals in and around joints, (4) interstitial deposition of urate crystals in renal parenchyma, and (5) urolithiasis
Copyright 1998 McGraw-Hill. All rights reserved.

Gout

Affects less than 0.5% of the population Due to familial disposition, incidence may be as high as 80% in families affected by disorder.

Stoffey et al, Emed 2002

Gout

Typical sequence involves progression through:

asymptomatic hyperuricemia acute gouty arthritis interval or intercritical gout chronic or tophaceous gout

Pathophysiology

Urate saturates in plasma at 7 mg/dL

Assuming pH, temp, Na are WNL

MSU deposits in less vascular tissue

Cartilage Tendons/ligaments

There is a predilection for peripheral joint/tissue

Pathophysiology

Primary gout:
Overproducers: 10% Under-excretors: 90%

Secondary gout:
Excess nucleoprotein turnover (lymphoma, leukemia) Increased cell proliferation/death (psoriasis) Rare genetic disorder Lesch-Nyan Syndrome pharmaceuticals

Signs and Symptoms

Acute attack:
Over hours frequently nocturnal Excruciating pain Swelling, redness and tenderness Podagra: 1st MTP classic presentation May effect knees, wrist, elbow, and rarely SI and hips.

Chronic:
Destructive tophacous Much greater chance if untreated Rarely presents as a chronic

Signs and Symptoms

Renal lithiasis Uric acid nephropathy Urate nephropathy

Diagnosis

Based on history and physical Confirmed by arthrocentesis

Urate crystals: needle-shaped negatively birefringent either free floating or within neutrophils & macrophages. 30% may show normal level

Uric acid level non specific.

Urine collection:

<800 mg underexcertor(<600 purine-free diet)

Microscopic Diagnosis

X-ray Acute
Soft

tissue swelling

Chronic

chronic tophaceous gouty arthritis, extensive bony erosions are noted throughout the carpal bones Sclerosis and joint-space narrowing are seen in the first metatarsophalangeal joint, as well as in the fourth interphalangeal joint .

Differential Diagnosis

Septic arthritis: must be excluded CPPD Acute Rheumatic fever Palindromic Rheumatism Psoriatic arthritis

Treatment

Acute:

NSAIDs anti-inflammatory doses Colchicine 0.5 mg po q2 hours, may require 6 mg.

Stop with response or side effect Can be used for chronic disease, increased risk for BM suppression

Aspirate followed by administration of corticosteroids Prednisone ACTH 40-80 IM/IV or Solumedrol Opiates and Tylenol

Treatment

Chronic:
Diet will decrease uric acid 1 mg/dL at best Weight loss Limit ETOH Modification of medications

Avoid low dose ASA, diuretics, etc.

Treatment

Chronic

Uricosuric: for under-excretors

Probenicid: Sulfinpyrazone: toxic side effects Avoid with renal disease Consider NSAIDs to avoid exacerbation of gout

Treatment

Chronic

Indications for Allopurinol

Tophaceous deposites Uric acid consistently >9 Persistent Sx with moderate UA levels Impaired renal function Prophylaxis for tumor-lysis syndrome

Consider NSAIDs to avoid exacerbation

Prognosis

Generally good More severe course when Sx present < 30 y/o Up to 50% progress to chronic disease if untreated. Surgical intervention may be required for tophi.

References

Harrisons 14th Edition

Copyright 1998 McGraw-Hill. All rights reserved.

Currents, Medical Diagnosis & Treatment, 2001 http://animatedmedical.com/Gout/Gout.html Smelser et al, Emed 2002