Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Gout and pseudogout

4,611 views

Published on

Crystal Arthritis - gout and pseudogout

  • DOWNLOAD FULL BOOKS, INTO AVAILABLE FORMAT ......................................................................................................................... ......................................................................................................................... ,DOWNLOAD FULL. PDF EBOOK here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... ,DOWNLOAD FULL. EPUB Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... ,DOWNLOAD FULL. doc Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... ,DOWNLOAD FULL. PDF EBOOK here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... ,DOWNLOAD FULL. EPUB Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... ,DOWNLOAD FULL. doc Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... ......................................................................................................................... ......................................................................................................................... .............. Browse by Genre Available eBooks ......................................................................................................................... Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult,
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • How can I get rid of my belly fat? ➤➤ https://tinyurl.com/y6qaaou7
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

Gout and pseudogout

  1. 1. Dr.Angelo Smith M.D WHPL
  2. 2. "Be temperate in wine, in eating, girls, and sloth, or the Gout will seize you and plague you…" -- Franklin
  3. 3.  History:  Galen (129-199 AD), an ex-gladiatorial surgeon in the Pergamon arena in Asia Minor who moved to Rome, described gout as a discharge of the four humors of the body in unbalanced amounts into the joints (hence gout = gutta, a drop).  The first radiological description of gout was made by Huber in 1896, a few months after Röentgen described the x-ray.
  4. 4.  Monosodium urate  Calcium pyrophosphate dihydratte  Hydroxyapatite  Corticosteroid esters  Calcium oxalate
  5. 5. GOUT (monosodium urate) PSEUDOGOUT (calcium pyrophosphate) HYDROXYAPATITE
  6. 6.  Inflammatory arthritis mediated by the crystallization of uric acid within joints, tophi  Often associated with hyperuricemia  Incidence: 62.3 /100,000 (2-fold increase)  Associations: DM, HTN, metabolic syndrome, obesity, CVD, renal stones, CPPD  Risk Factors: genetics, age, CRF, serum uric acid, diet, alcohol, medications
  7. 7. Uric Acid Balance
  8. 8.  Uric acid: overproduction vs. underexcretion  Mechanisms of urate “production”  cellular nucleoproteins/nucleotides (~ 66%)  diet (~33%)  Mechanisms of urate excretion  kidney (~66%)  gut (~33%)
  9. 9.  Completely filtered by the glomerulus  Completely (essentially) reabsorbed in the proximal tubule  Approximately 50% is secreted back into the tubule in the descending loop  Approximately 80% (of the 50% now in the loop) is reabsorbed in the ascending loop  Net excretion = 10% of filtered load
  10. 10.  Hyperuricemia alone does NOT make a diagnosis of gout -only a subset of people with hyperuricemia will develop gout -probability of gout increases with higher uric acid levels  Asymptomatic hyperuricemia generally requires no treatment
  11. 11.  Hyperuricemia (>7.0 mg/dl) in 5% - 8% of male population.  Most (about ⅔) are forever asymptomatic.  80% of gouty patients have uric acid < 9 mg/dl.  Above 10 mg/dl, risk rises rapidly.  Gout is the most common cause of monarthritis in middle-aged and elderly men (8% yearly prevalence).
  12. 12.  Lymphomas (esp. Hodgkin’s disease)  Myeloproliferative disorders  Diabetes  Psoriasis  Sarcoid  Glycogen storage disease
  13. 13.  Urate precipitation leads to acute gouty arthritis  Local factors – temperature, pH, trauma, joint hydration  Systemic factors – hydration state, fevers, meds, alcohol, co-morbid conditions  Attack resolves spontaneously 10-15 days
  14. 14.  Lasts several days to several weeks.  May spread from joint to joint.  Often accompanied by fever, leukocytosis.  Gets worse as the years go on.  Pain appears last, disappears first.  Petite attacks occur (lasting hours).
  15. 15.  ACUTE GOUT  First attack 4th-6th decade for men  Women almost always postmenopausal  Classically monoarticular LE– podagra (50%), (vs pseudopodogra) >ankle >gonagra >upper extremity.  Proximal joint, central arthropathy uncommon
  16. 16.  MSU  CPPD  Hydroxyapatite  Septic  Psoriatic, Reiter’s  Rheumatoid
  17. 17.  Evidence-based medicine based on EULAR (ESCISIT) – 10 key points  Acute attack 6-12 peak intensity with S/W/E/T  Aspiration always recommended if possible  Prompt polarized microscopic analysis performed  Definitive Dx – requires crystal confirmation  Gout and Sepsis can coexist – fluid should be sent Gram’s stain, culture  Serum uric acid levels neither confirm nor exclude gout  Radiographs not necessary  Risk factor assessment
  18. 18.  Hyperuricemia  biochemical hallmark of gout, but not by itself diagnostic for gout  Leukocytosis  Increased ESR  Synovial Fluid  leukocyte counts = septic arthritis  viscosity is < septic or inflammatory arthritis  MSU needle - like intracellular & extracellular crystals  Negatively birefringent crystals under polarized light microscopy
  19. 19.  THERAPY (for all crystal diseases):  Corticosteroids: intrarticular > systemic  NSAIDs – fast acting full dose if no contraindications  Colchicine (PO,IV route dangerous) ▪ narrow therapeutic window ▪ Bone marrow suppression, myopathy, neuropathy ▪ purgative effects – “Pt often run before they walk”  ACTH  NEVER ALLOPURINOL
  20. 20.  70% prevelance of MSU crystals remain in the joint  Lasts months to years for 75-80%, 20% never have another attack
  21. 21.  Lifestyle, dietary modification  Diet high in vegetables, dairy, water beneficial  Initiate uric acid lowering therapy after 1(?) or 2 episodes of acute gouty arthritis  Always prophylaxis for first 6 months with low dose steroids, NSAIDs, or colchicine
  22. 22.  USUALLY PRESENT AFTER 10YEARS OF ACUTE INTERMITTANTGOUT  TOPHI DEPOSITION  CHRONIC SWOLLEN JOINTS  JOINT DESTRUCTION  ABSOLUTELY REQUIRES ALLOPURINOL
  23. 23.  Overhanging edges  Punched out lesions with sclerotic borders.  Preservation of joint space (till late)  Degenerative changes
  24. 24. The “Double Contour Sign” of Gout. Filippucci E, Grassi W Department of Rheumatology, University of Ancona, Italy
  25. 25.  Gout  hallux, ankle, knee, hand  younger, male  Pseudogout  knee, wrist, ankle  older, female  Almost any joint can be affected by either disease!
  26. 26.  Aging  Previous joint surgery  Previous joint trauma  Familial types  Gout  Amyloidosis  Hyperpara  Hemochromatosis  Hypomagnesemia  Familial hypocalciuric hypercalcemia  Hypophosphatasia  Wilson’s disease  Ochronosis
  27. 27. CHONDROCALCINOSIS  Acute arthritis caused by Calcium pyrophosphate dihydrate (CPPD) crystal-induced inflammation  May perfectly mimic gout during acute flare  Attacks occurring before age 50 are uncommon Clinical:  Most often affects the knee and the wrists Radiology:  Calcification densities in hyaline or fibrocartilage, which are found in knee menisci, acetabular labrum, & TFCC
  28. 28.  Fluid analysis:  CPPD crystals are visualized under compensated polarized light microscopy  crystals may be more difficult to detect than MSU crystals because of their smaller size, more intralysosomal location, & less brilliant colors  CPPD crystals show weak positive birefringency and have squared or rhomboidal shaped ends  alizarin red stain, can confirm that these clumps are masses of calcium crystals Treatment:  aspiration of the involved joint and steroid injection, once diagnosis of infection has been excluded, will usually control symptoms
  29. 29.  Hydroxyapatite  Calcium carbonate  Octacalcium phosphate  Tricalcium phosphate (whitlockite)  Hydroxyapatite is non- birefringent.
  30. 30.  Acute monoarthritis (pseudopseudogout)  Acute calcific tendinitis, bursitis  Scleroderma, dermatomyositis  Heterotopic calcification  Milwaukee shoulder  Crowned Dens Syndrome
  31. 31.  Is usually a peri-arthritis.  Intense inflammation (looks septic)  Synovial fluid often non-inflammatory.  Often causes podagra (especially in younger women).  Look for the telltale calcifications on radiographs.
  32. 32.  Severe, destructive shoulder arthropathy.  Seen in elderly females with DJD of shoulder.  High-riding humeral head on radiographs (large rotator cuff tear).  Non-inflammatory fluid with BCP crystals.
  33. 33.  Is an association of acute cervical pain and calcifications in the peri-odontoid space.  This disease affects only adult females.  Patients present with inflammatory signs, can be treated with non-steroid anti- inflammatory drugs and recover without sequela.  CPPD deposition can also lead to this syndrome.  Radiologically - crowned dens.

×