CLINICAL SCIENCE SESSION GOUT ARTHRITIS

Oleh : Mohamad Rizki Dwikane Preseptor : dr. Dyana, Sp.Rad

RSUD AL-IHSAN BANDUNG 2014

 Gout merupakan istilah yang dipakai untuk sekelompok gangguan metabolik yang ditandai oleh meningkatnya konsentrasi asam urat (hiperurisemia). Gout ditandai dengan peningkatan kadar asam urat dalam tubuh dan menyebabkan inflamasi (radang) pada persendian (artritis).

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 Gout adalah bentuk inflamasi arthritis kronis, bengkak dan nyeri yang paling sering di sendi besar jempol kaki. Gout tidak terbatas pada jempol kaki, dapat juga mempengaruhi sendi lain
pergelangan kaki, lutut, lengan, pergelangan tangan, siku dan kadang di jaringan lunak dan tendon.

Hanya mempengaruhi satu sendi pada satu waktu, Dapat menjadi parah dari waktu ke waktu dapat mempengaruhi beberapa sendi.
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 GOUT Deposition of sodium urate monohydrate crystals in synovial membranes, articular cartilage, ligaments, bursae leading to destruction of cartilage. - Disorder of purin metabolism.

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Epidemiologi
- > 40 th - pria> wanita - > at 1st MTP joint - usually not seen until 6-12 years after initial attack

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Etiologi
Hiperurisemia dan Gout primer
Hiperurisemia primer adalah kelainan molekular yang masih belum jelas diketahui. 99% kasus adalah gout dan hiperurisemia primer. Terdiri dari hiperurisemia karena penurunan ekskresi (80-90%) dan karena produksi yang berlebih (10-20%).

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 Hiperurisemia dan Gout sekunder

Gout sekunder dibagi menjadi beberapa kelompok yaitu kelainan yang menyebabkan peningkatan biosintesis, kelainan yang menyebabkan peningkatan degradasi ATP atau pemecahan asam nukleat dan kelainan yang menyebabkan sekresi menurun.

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 Hiperurisemia dan Gout idiopatik

Hiperurisemia yang tidak jelas penyebab primernya, kelainan genetik, tidak ada kelainan fisiologis dan anatomi yang jelas.

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Faktor resiko
Suku bangsa /ras Konsumsi alkohol Konsumsi ikan laut Penyakit Obat-obatan Jenis Kelamin Diet tinggi purin
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 Gout arthritis, meliputi 3 stadium

Gout arthritis stadium akut Stadium interkritikal Stadium Gout arthritis menahun

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Lokasi:
o Joints: - hands + feet (1st MTP joint most commonly affected = podagra), elbow, wrist - Carpometacarpal compartment especially common), knee, shoulder, hip, sacroiliac joint (15%, unilateral) o Ear pinna > bones, tendon, bursa

PATOGENESIS GOUT ARTRITIS

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MANIFESTASI KLINIS
The nighttime attack of swelling, tenderness, redness, and sharp pain in big toe , foot, ankle, or knees. The attacks can last a few days or many weeks before the pain goes away. Another attack may not happen for months or years.

 Perubahan radiologis hanya terjadi setelah bertahun tahun timbulnya gejala. Terdapat predileksi pada sendi MTP pertama. Walaupun pergelangan kaki, lutut, siku, dan sendi lainnya dapat terlibat.

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Ciri khas gout

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Radiologic features (1)

: DEPOSIT KALSIFIKASI (= tophy)
: intra/eksta artikulererosion (= punch out lesion) : TDK ADA DEMINERALISASI demineralisasi : Kadang ditemukan adanya kista oval sub artikuler : Art narrowing : artikuler swelling some time with chondro calsinosis : Tidak ada celah antar joint

: Little or no osteoporosis : Soft tissue swelling : Tophy not calcified

Dense soft tissue Tophi, preservation of joint space, Bone erosions (marginal periarticular) overhanging margin sign Metatarsophalangeal joint

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Radiologic features (2)

Soft tissue findings o Calcific deposits in gouty tophi in 50% (only calcium urate crystals are opaque) o Eccentric juxta-articular lobulated soft-tissue masses (hand, foot, ankle, elbow, knee) o Bilateral olecranon bursitis o Aural calcification Joint findings o Absence of periarticular demineralization o Erosion of joint margins with sclerosis o Cartilage destruction late in course of disease o Periarticular swelling (in acute monarticular gout) o Chondrocalcinosis (menisci, articular cartilage of knee) resulting in secondary osteoarthritis

Radiologic features (3)

Bone findings o "Punched-out" lytic bone lesion sclerosis of margin o "Mouse / rat bite" from erosion of longstanding soft-tissue tophus o "Overhanging margin" (40%) o Ischemic necrosis of femoral / humeral heads o Bone infarction

Figure 1 is an X-ray of a normal foot with healthy bones and joints. Figure 2 is an X-ray of a deformed toe joint caused by chronic gout.

The great toe Demonstrates extensive juxta-articular (near joint) erosions with soft tissue swelling and little osteoporosis

Early-phase 1 -limited to the soft tissues -asymmetric swelling around the affected joint, -edema of the soft tissues around the joints, -multiple episodes of gouty arthritis in the same jointa cloudy area of increased opacity

intermediate phase 2 -the earliest bony changes appear(initially appear in the first metatarsophalangeal joint area), generally seen outside the joint or in the juxta-articular area. -often described as punched-out lesions, which can progress to become sclerotic as they increase in size. -Fractures may be present in affected areas in severe cases of intermediate-phase gout.
late-phase 3 -the hallmark findings are numerous interosseous tophi. -joint-space narrowing, which can be severe and symptomatic. -Marked deformities and subluxation may also be noted in affected areas during the late stage of disease. -Calcific deposits in the soft tissues also can be observed in late-phase gout.

Wassalamualaikum.

TERIMA KASIH

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