Rheumatology seminar for undergraduate medical students, Baghdad Medical College

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Definition
Causes
Risk
Factors
Clinical
Presentation
Investigation
Objectives

3. • It’s a type of crystal induced arthopathies (crystal deposit inside and around
the joint leads to acute inflammation and chronic diseases )
• Pathogenesis is intra-articular deposition of monosodium urate MSU crystals
due to disorder of urate metabolism ( means hyperurecemia)
• Causes of hyperurecemia are:
Cell turnover (hymolysis, blast crisis, tumor lysis, myelodyplasia, psoriasis)
Cyclosporine
Dehydration
Diabetes insipidus
Diet (red meat, alcohol)
Diuretics
Lead poisoning
Lesch Nyhan syndrome
Salicylates (low dose)
Starvation
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4. • Gout is a diseases affect middle age men (91% men)
( M:F ratio is 10:1 )
• Female attacks mostly after fifth decade (menopause)
• There are certain events precipitate the gout sometimes preceded
the attack
I. Excessive alcohol consumption
II. Red meat intake >>>> obesity
III. Trauma
IV. Surgery
V. Infection
VI. Steroid withdrawal
VII.Drugs (diuretics; HCTZ, furosemide// anti TB drugs ( pyrazinamide, ethambutol)
VIII.Serious medical illness
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A 32-year-old man comes with a history of right ankle
swelling that occurred the night before. He has noticed
that his ankle has been red, warm, and very painful.
He occasionally drinks alcohol. On examination you find a
red swollen ankle with evidence of an effusion. The range
of motion is restricted.

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• Sudden onset of monoarticular pain
• The affected joint looks warm, swollen and tender (just like cellulitis)
• Commonly occur at night waking the patient from sleep
• Most common joint affected is MPT joint especially of the big toe (podagra);
other joint are: knee, ankle, PIPs, DIPs
• Deposition of urate crystals in connective tissue (tophi) (mostly in chronic
cases)
• Kidney stones (mostly in chronic cases)
Look for a man with
sudden onset of severe
pain in the toe at night,
the toe is red, swollen
and tender

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• Arthrocentesis (synovial fluid analysis) (best initial test)
1. MSU crystals are negative birefringent and needle shape on polarized
light examination
2. WBCs count 5000 to 50000
• X ray of the affected joint (erosive calcification)
• Serum uric aid
During the acute attack would low or normal (have no value in acute
cases)
In chronic cases would be helpful for follow up
• Renal function tests (why ?)

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Acute gouty arithritis
• NSAIDs (indomethacin) *
• Colchicine
• Steroids
Chronic hypourecemic therapy
• Allopurinol *
• Febuxostat
• Pegloticase
• Probenecide
• Avoidance of the rigger factors

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A 32-year-old man comes with a history of right ankle
swelling that occurred the night before. He has noticed
that his ankle has been red, warm, and very painful.
He occasionally drinks alcohol. On examination you find a
red swollen ankle with evidence of an effusion. The range
of motion is restricted.

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• What is the first step in this patient?
• What do we do after confirming the diagnosis?
Six months after the first episode he comes back to your office with left knee
swelling. A red, warm knee is noted on examination.
• What is the first step now?
• What do you do after confirming the diagnosis?
On a routine visit the same patient has had 4 documented episodes of gout
despite limiting alcohol and diet.
• What would be the appropriate next step here?

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‫سؤال‬ ‫عند‬ ‫محد‬ ‫أكيد‬

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