another common cause of arthropathy

1. Gout and Other Crystal Deposit Diseases
Prof G S Patnaik

2. Crystal deposition disease

3. Crystal deposition disease
Group of conditions : presence of crystals
in & around joints, bursae & tendons
• Gout
• CPPD (calcium pyrophosphate
dihydrate)
• Hydroxyapatite

4. GOUT
Consequences : crystal deposition
• Remains inert and asymptomatic
• Induces acute inflammatory
reaction
• Slow destruction of the affected
tissue

5. Gout
• Disorder of purine metabolism
• Common in males m:f = 20:1
• In females after menopause
• Hyperurecemia
– Monosodium urate monohydrate crystals
• Recurrent acute synovitis
Two types:
• Primary 95%: Inherited disorder
• Over production / under excretion of uric acid
• Secondary 5% : Acquired condition
• Over production
• Myeloproliferative disorders
• Under excretion
• Renal failure

6. Two types:
• Primary 95%: Inherited disorder
• Over production / under excretion of uric
acid
• Secondary 5% : Acquired condition
Over production Under Excretion (renal Failure)
• Myeloproliferative disorders

7. Gout
Pathology :
• All patients with a high serum uric acid do
not develop gout
• Crystals are deposited in minute clumps :
remain inert for years
• Local trauma ? disperses crystals into joint
: acute inflammatory reaction

8. Pathology .. Gout…
• Each crystal : phagocytosed or float free
in the joint
• Over years, urate deposits build up in
joints , periarticular tissue,tendon and
bursa :destroy articular cartilage and
periarticular bone

9. Pathology :
Common sites of deposition :
• MTPJ of great toe
• Achillis tendon
• Olecrenon bursa
• Pinna of the ears
• Tophi : < 1cm to several cms : may ulcerate
through the skin
Gout

10. Gout
Clinical features :
• Men > 30 yrs of age
• Women after menopause
• Obese, hypertensive, alcohol friendly
• Patients on diuretics : (increases tubular re-absorption
of uric acid)
• Family history : positive

11. Gout
Acute gout :
• Sudden severe joint pain, ? precipitated by
• Minor trauma
• Surgery
• More in the night
• Lasts for 1-2 wks and completely resolves
• Minor illness
• Unaccustomed exercise
• Alcohol

13. Gout
Clinical features: Acute Gout
• Common sites are affected
• Joint hot and tender : d/d : septic arthritis
• Hyperurecemia not diagnostic
• Diagnosis confirmed by synovial fluid analysis for
negatively bifringent urate crystals

14. Gout
Chronic gout
Recurrent attacks
• increased joint stiffness & deformity
• Tophi appear over the common sites
• Large tophi may ulcerate the skin
• Chalky material discharged
• Renal calculi, renal parenchymal disease

15. Gout
Radiology :
Acute gout : Only soft tissue swelling
Chronic gout
• Tophi appear as punched out lesions (cysts) in
the para- articular bone ends
• Secondary osteoarthrosis
• Infected bursitis

16. Gout
Differential Diagnosis:
• Infection
• Cellulitis
• Septic arthritis
• Infected bursitis
Reiter’s disease
• History more protracted
• Response to Nsaids less

17. Gout
Differential Diagnosis :
Pseudogout
• Affects larger joints
• More common in women
• Pyrophosphate dihydrite crystalsdeposition
Rheumatoid arthritis
• Polyarticular gout : affecting fingers
• Elbow tophi : mistaken for subcutaneous nodule
– Biopsy establishes diagnosis

18. Gout
Treatment
Acute stage
• Rest to the joint
• Nsaids
• Aspiration
Interval therapy
• Loose weight
• Reduce alcohol
• Eliminate diuretics
• Urocosuric drugs
– allopurinol
Interval therapy indicated :
• Acute attacks occur at frequent
intervals
• Presence of tophi
• When renal function is affected
• Colchicine less effective
• Intra-articular hydrocortisone

20. Gout
Interval therapy
• Loose weight
• Reduce alcohol
• Eliminate diuretics
• Urocosuric drugs
– allopurinol
Interval therapy indicated :
• Acute attacks occur at frequent
intervals
• Presence of tophi
• When renal function is affected

21. Gout
Interval therapy:
• Urocosuric drugs : if renal function is normal
• Allopurinol : xanthine oxidase inhibitor :
preferred
– These drugs are never started in acute stage
– They should be always covered by NSAID’s /
Colchicine as they will otherwise precipitate an
attack of gout
Chronic gout:
• Allopurinol is the drug of choice
• Ulcerating tophi may have to be evacuated