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Gout

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Gout

  1. 1. Gout MDEMO Student Presentation
  2. 2. Structure of presentation • What is gout? • Epidemiology • Pathogenesis • Clinical features • Differential diagnoses • Investigations • Management • Summary
  3. 3. What is gout? • Crystal-induced inflammatory arthritis • Associated with hyperuricaemia • Usually monoarticular – ‘podagra’ of 1st MTP joint
  4. 4. Epidemiology • UK prevalence 0.5 - 1% • Hyperuricaemia in 5% • Classically affects middle-aged males • Male:female ratio 10:1 • Menopause can precipitate gout
  5. 5. Henry VIII suffered from gout... Podagra: acute gout in 1st MTP joint
  6. 6. Pathogenesis • Serum urate ↑ after puberty & menopause • Urate production-elimination imbalance • Urate crystalises with ↑ concentration • Hyperuricaemia seen with: • ↑ age, obesity, high-protein diet, alcohol • Positive family history
  7. 7. Pathogenesis • Urate overproduction due to: • Excess purine ingestion • Excess purine synthesis • Inborn error of metabolism (<1%) • Impaired urate excretion by kidneys
  8. 8. Pathogenesis – purine metabolism Cell nucleic acids hypoxanthine xanthine urate xanthine oxidase
  9. 9. Examples of purine-rich foods
  10. 10. Inflammation • Neutrophils • Pro-inflammatory enzymes • Complement activation • Inflammatory arthritis
  11. 11. Clinical features • Hyperuricaemia may cause: • ‘Gout’ – acute urate synovitis • Chronic polyarticular gout • Chronic tophaceous gout • Urate kidney stones
  12. 12. Soft tissue tophi
  13. 13. Clinical features of gout • Classic acute nocturnal agonising pain • Precipitants may be obtained from history • 1st MTP joint affected in >50% - podagra • Mild pyrexia
  14. 14. Differential diagnoses • Acute septic arthritis • Infective cellulitis • Chondrocalcinosis – pseudogout (pyrophosphate crystals)
  15. 15. Investigations • History & Examination • Joint fluid microscopy • Serum urate – may be raised: Male >420 μmol/l Female >360 μmol/l • Urea and creatinine to assess renal function
  16. 16. Negatively birefringent crystals: urate Positively birefringent crystals: pyrophosphate
  17. 17. Management • Aims • manage symptoms • prevent exacerbations • reduce serum urate • Acute and long-term strategies
  18. 18. Management – medical • Acute: NSAIDs, colchicine, steroids • Long-term: Prophylaxis with xanthine oxidase inhibitors • allopurinol • febuxostat – recent (2008) • Uricosurics – e.g. probenecid • Mammalian urate oxidase – experimental
  19. 19. Purine metabolism Cell nucleic acids hypoxanthine xanthine urate xanthine oxidase allopurinol febuxostat --
  20. 20. Management – lifestyle • Weight loss • Diet – reduction of • Calories • Lipids • Protein-rich foods • Alcohol ...but keep hydrated
  21. 21. Gout summary • Crystal-induced inflammatory arthritis • Associated with hyperuricaemia • Males >> Females • Podagra – 1st MTPJ symptoms • Investigations • Differential diagnoses • Acute and long-term management

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