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Gout summary
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Gout summary


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  • 1. Gout HistoryMono/ oligoarticular crystal arthropathy characterised by presence of negatively Joints monoarticular + - progressing to oligoarticular involvement • stbirefringent uric acid crystals in joints; associated with hyperuricemia 1 metatarsal • knees, ankles• inflammation believed to be due to WBCs phagocytosing urate crystals; WBCs acute onset release inflammatory mediators • pain, swelling, warmth, decreased movement, loss of function• 90% men, women mostly postmenopausal asymptomatic between attacks• >30y To exclude Autoimmune/ CTD other causes of • alopecia, malar rash, photosensitivity, oral ulcersClinical Manifestations (5) arthritis • nodules, conjunctivitis, keratitis• asymptomatic hyperuricemia (technically not gout) • stretching of skin, dysphagia• acute arthritis • systemic involvement – lungs, cardiac, renal• chronic tophaceous gout IBD• urate urolithiasis • chronic bloody mucoid diarrhea• urate nephropathy • eye involvement GonococcalDDx: • sexual history• Septic Arthritis (can coexist with gout) • urethral discharge• Pseudogout Reiters• If oligoarticular, rheumatoid arthritis • genital ulcers, diarrhea, conjunctivitis• other autoimmune conditions Reactive • st history of diarrhea/ URTI 2 weeks before 1 episode Skin Tophi (big toe, ears, hands, feet)Causes of gout pruritis, desquamation of surrounding skin after attack Renal Renal colic, loin to groin pain suggesting stonesPrimary Hyperuricemia S/S CRFIncreased production of purine Idiopathic • decreased urine output 0 Genetic Enzyme Defects e.g. Lesch 2 causes Malignancies Nyhan Syndrome • LOW/ LOADecreased renal clearance of uric acid Idiopathic • LNs Anemia historySecondary Hyperuricemia Long-standing renal diseaseIncreased turnover of purine Malignancies Drug history • myeloproliferative disorder MTX/ aspirin/ diuretics • lymphoproliferative disorder e.g. Gout • as follows leukemia Medications Chronic hemolytic anemias Associated • HTN Cytotoxic drugs e.g. MTX Metabolic • DMDecreased renal clearance of uric acid Renal disease conditions • Hyperlipidemia Drug-induced • IHD • low dose aspirin • loops and thiazides
  • 2. Physical Exam (Short Case Style) Between Attacks Lifestyle changes lose weight stFeet palpate tophi - podagra seen on 1 metatarsal joint avoid alcohol palpate metatarsal – warm/ tender? suggests acute attack avoid hyperuricemia medxOther joints Ankles, knees avoid purine-rich foods – allTophi Olecranon bursa meats, yeasts, beans, seafood Helix of ear Allopurinol avoid during acute attacks, rash -> SJS Achilles tendons (xanthine oxidase exacerbates it hepatitisCauses of • LNs and abdomen to suggest hemato malignancy inhibitor) good forsecondary gout • Signs of CRF – sallow skin, pruritus • chronic tophaceous goutComplications • Signs of CRF – sallow skin, pruritus • urate renal stonesAssociated mtb • BP – HTN • urate nephropathyconditions • dipstick - glycosuria Uricosurics probenicid • ineffective in patients with sulfinpyrazole renal insufficiency • MUST encourage drinking lots of water,Investigations ensure urine output• confirm diagnosis of gout >2L/day, else crystals• etiology of gout may form in GU tract• complications of gout• associated metabolic conditionsBloods FBC+PBF • raised WBC suggest septic arthritis • grossly raised WBC + blasts suggest blood CA Serum uric acid level U/E/Cr for RFRadio Xray affected joint • soft tissue swelling • punched-out erosions adjacent to tophi strongly suggests goutJoint aspiration send for cultureif acute attack send tor histopatholody • neddle-shaped crystals, negatively birefringentAssociated • fasting plasma glucoseconditions • serum lipidsManagementAcute EpisodeBed Rest For 24h after pain subsides Digitally signed by DR WANA HLA SHWENSAIDS Indomethacin DN: cn=DR WANA HLA SHWE, c=MY, o=UCSI University, School of Medicine, KT-Campus, Colchicine Abdominal cramps Terengganu, ou=Internal Medicine Group, D+V Reason: This document is for UCSI University, School marrow suppression of Medicine students. renal Date: 2009.02.26 15:04:08 +0800 Steroids if above don’t work