- See:
-
Pseudogout
-
Therapeutic Principles &
Anti-Gout Meds
- Discussion:
- gout refers to articular dz of MSU deposits (tophi) in soft tissues.
- it is caused by deposition of monosodium urate crystals in poorly perfused tissues, as well as bursae, ligaments, articular cartilage, and synovial membranes;
- on avgerage, a family history of gout can be obtained in less than half patients'
- male / female ratio ranging from 7:1 to 9:1
- females with gout tend to be postmenopausal;
-
pathophysiology
-
predisposing conditions:
- common chronic diseases assoc w/ gout include alcoholism, obesity, hypertension, CAD, and hypertriglyceridemia;
- increased dietary purine intake;
- decreased puring biosynthesis (lack of serum enzyme uricase);
- medications: thiazide diuretics and antimetabolites
- conditions which increase purine biosynthesis:
- myeloroliferative disorders (polycythemia, AGL, CGL)
-
multiple myeloma;
-
sickle cell;
- prolonged use of diuretics (thiazide diuretics may precipitate gout);
-
diff dx:
-
prognosis:
- arthritis remits completely and then recurs with increasing frequency;
- in a pt w/ h/o acute gout, there is an 86% occurance of recurrent acute attack 3-5 days postoperatively if no prophylaxis is used;
- after 1st attack, 2/3 of these pts will develop 2nd attack w/in 1 year;
- w/in 2 years, three fourths will suffer a second attack;
- 1/10 of these pts will not have 2nd attack for following 10 years;
- w/ chronic gout, tophi develop in cartilage, tendons, and bursae in some patients
- Clinical Presentation:
- age: attacks of gout usually begin in males between ages of 30 and 50;
- when women are affected they are usually post-menopausal (and are not on supplemental estrogen);
- gout in women should prompt a more detailed work up of enzyme deficiency;
- patients may complain of very mild attacks developing w/o provocation that abate w/o specific treatment;
-
podagara:
- classic presentation of acute attack of first MTP joint;
-
hand:
- may be confused with a
hand infection;
- may present with synovial swelling, joint swelling, tenosynovitis;
- in the hand look for oval periarticular erosions;
- multiple erosions will be distributed throughout the carpi and phalanges bilaterally;
- erosions have sclerotic borders and will often have overhanging edges;
- unlike classic
RA, in early gout, hand and wrist joints will have preserved joint spaces and normal mineralization;
-
nephrolithiasis is major extraarticular manifestation;
- in the urinary tract, the pH is less than 5.7, which causes urate to form of uric acid, which has poor solubility
can cause precipitation of uric acid crystals;
- only small % of pts w/ gout get tophi, but many get renal stones;
- pure uric acid stones are found in 80%, & uric acid is probably nidus for Ca-Phos & oxalate calculi in remainder;
- in 1/2, sx from renal stones actually precede arthritis.
- Laboratory Studies for Gout
- Radiographs:
- in the hand look for oval periarticular erosions;
- multiple erosions will be distributed throughout the carpi and phalanges bilaterally;
- erosions have sclerotic borders and will often have overhanging edges;
- unlike classic
RA, in early gout, hand and wrist joints will have preserved joint spaces and normal mineralization;
- example:
- case of histologically proven gout involving the proximal 5th metatarsal:
- Therapeutic Principles &
Anti-Gout Meds
Systemic steroid therapy for acute gout: a clinical trial and review of the literature.
Local ice therapy during bouts of acute gouty arthritis.
Relation between adverse events associated with allopurinol and renal function in patients with gout.
Purine-Rich Foods, Dairy and Protein Intake, and the Risk of Gout in Men.
The Severe Gout of Emperor Charles V
