Gout

Question 1

Gout is characterized by ____ deposition throughout the body

Answer 1

uric acid crystalline
(sodium monourate crystals)

Question 2

Uric acid is a normal byproduct of ____

Answer 2

purine metabolism

Question 3

What population is primarily affected by gout?

Answer 3

older (40-50s) men (9:1)
(males naturally produce more uric acid than females)

Question 4

What is elevated in the blood to predispose someone to gout?

Answer 4

uric acid

Question 5

What are the potential causes of gout?

Answer 5

• idiopathic impairment of renal uric acid excretion (85%)
• genetic problem w/ purine metabolism
• alcoholism (beer & red wine)
• diabetes (long-term, poorly controlled) damages renal function
• stress-induced (?)

Question 6

Why do beer and red wine predispose someone to gout?

Answer 6

• high in purines
• may lead to renal disease

Question 7

Describe the pathogenesis of gout prior to diagnosis

Answer 7

• overproduction of purine metabolic byproducts (uric acid)
• inability to dispose of/break down metabolic byproducts
• asymptomatic = hyperuricemia (uric acid crystals are not irritating)
• eventually symptomatic = gout Dx

Question 8

Most cases of gout are (primary/secondary)

Answer 8

secondary

Question 9

What is primary gout?

Answer 9

due to metabolic overproduction of uric acid

Question 10

What is secondary gout?

Answer 10

due to presence of underlying pathology

Question 11

What underlying pathologies can lead to gout?

Answer 11

• Renal disease
• Multiple myeloma (Bence Jones proteins)
• Alcoholism (red wine & beer)
• Diabetes

Question 12

Describe the pathogenesis of gout that prompts a diagnosis.

Answer 12

• Urate (sodium monourate) crystals precipitate into periarticular soft tissues
• Urate crystals phagocytized by PMNs + macrophages, inducing intense inflammatory reaction
• Takes average 7yrs to see radiographic findings

Question 13

Describe the pathogenesis of chronic gout.

Answer 13

• lysosomal & other enzymes released lead to jt. destruction
• if untreated, generally resolved in ~1wk
• can recur months to years later

Question 14

What is often the initial joint affected by gout?

Answer 14

big toe

Question 15

Gout in the big toe is called ____

Answer 15

Podagra

Question 16

What is the initial clinical manifestation of gout?

Answer 16

• acute arthritic pain begins at night, builds rapidly over 24hrs
• begins as 1 big, red, swollen joint (cardinal signs)
• avoids wearing shoes/socks
• lasts 1-2 weeks
• remission of varying lengths
• hyperuricemia

Question 17

What would be on your differential diagnosis list for a patient with 1 big, red, swollen joint within a day?

Answer 17

• septic arthritis
• gout
• cellulitis
• osteomyelitis

Question 18

How would you differentiate Gout from Septic arthritis?

Answer 18

• labs
• joint aspiration (pus vs clear w/ crystals)

Question 19

What locations are commonly affected by gout?

Answer 19

• big toe
• instep
• heel
• ankle
• knee
• wrist
  (peripheral jts.; NOT in the spine)
• can also affect bursa, tendon sheathes (soft tissues)

Question 20

What are the late stage findings of chronic gout?

Answer 20

• Tophi
• renal impairment

Question 21

The chalky crystalline deposits that accumulate in soft tissues over 10-20 years in gout is called ____

Answer 21

Tophi (tophus = sing.)

Question 22

What clinical manifestation is pathognomonic for gout?

Answer 22

Tophi

Question 23

What are the 4 stages of gout?

Answer 23

• asymptomatic hyperuricemia
• acute gouty arthritis
• polyarticular gouty arthritis
• chronic tophaceous gout

Question 24

What is another name for chronic tophaceous gout?

Answer 24

lumpy bumpy joint disease

Question 25

What food and beverages are high in purines and can predispose an individual to gout?

Answer 25

- red meat - red wine - beer - aged cheeses

Question 26

Gout is primarily a disease of ____ structures

Answer 26

soft tissue (does not have to be in jts.)

Question 27

A patient with recurring acute gouty arthritis who continues to eat copious amounts of red wine and aged cheeses is likely to develop ____

Answer 27

polyarticular gouty arthritis

Question 28

What causes the "lumpy bumpy" appearance of chronic gout?

Answer 28

tophi

Question 29

What are the radiographic characteristics of gout?

Answer 29

- marginal erosions ("**overhanging margins**") - periarticular erosions - intraosseous erosions - **corticated erosions** - soft tissue swelling

Question 30

What causes the radiographic appearance of periarticular erosions in gout?

Answer 30

crystals deposit into periarticular soft tissues --> inflammation erodes bone

Question 31

What causes "overhanging margin" sign in gout?

Answer 31

bone regrowth of marginal bone during remissions

Question 32

What causes corticated erosions in gout?

Answer 32

longer remission periods of gout allow for thin cortical bone to begin forming around erosions

Question 33

What is the average radiographic latent period for gout?

Answer 33

7 years

Question 34

What would you include on your list of differential diagnoses for extensive soft tissue swelling around the elbow?

Answer 34

- Olecranon bursitis ("water on the elbow") - septic bursitis - gout (in olecranon bursa)

Question 35

What are the treatment options for gout?

Answer 35

- Diet (less purines, ^H2O, bing cherry juice) - NSAIDs/corticosteroids (short term) Refer to rheumatology: - colchicine (for recurrent attacks) - allopurinol (inhibits xanthine oxidase) - uloric