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HPI
• A 52 yo male presents to his PCP on a Monday morning with exquisite right knee pain that started overnight. He spent Sunday tailgating with friends. He denies trauma or any previous episodes.
• What else would you like to know?
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PMH
• Medical Hx: hypertension, right ACL repair (1980)
• Family Hx: Father has gout, Mother has hypertension and hyperlipidemia
• Social: Former collegiate football player, divorced with 3 children, works as a cook at a diner
• What is your differential diagnosis?
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DDx
• Gout – primary, secondary• Chrondrocalcinosis (pseudogout)• Infective arthritis (gonococcal)• Septic joint• Rheumatoid arthritis• Osteoarthritis• Meniscal Injury• Ligamentous Injury (ACL, PCL, MCL, LCL)
• What do you want to do next?
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Physical Exam
• Height, 6’ 5”; Weight, 300 lbs; BMI, 36• Vitals: BP 150/90; T 98.9, HR 70, RR 18• Gen: Patient is cooperative but sitting uncomfortably with
right leg slightly flexed• HEENT, CV, Respiratory, Abdominal, Neuro, and Psych Exams:
wnl• Skin: warm, erythematous right anterior knee• Musculoskeletal: exam limited by patient’s pain tolerance
• What labs do you want to orderand why?
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Lab Tests
a) Joint aspiration with synovial fluid analysis – Can differentiate gout/pseudogout, osteroarthritis, and
septic joint based on number of leukocytes– Can differentiate gout and pseudogout based on
crystals
b) CBC, ESR, CRP – rule out septic joint, infective arthritis
c) Serum uric acid level – limited value, can be high without gout or low during
acute attack
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Lab Results
• CBC – normal• ESR – 24 mm/h• CRP – 15 mg/L• Serum Uric Acid – 8.5 mg/dL• Synovial Fluid– 20,000/mm3 leukocytes• Osteoarthritis < 2,000, Gout/Pseudogout 5,000-50,000,
Septic Joint > 50,000
– See next slide for microscopic view
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Synovial Fluid
• negatively birefringent, needle-shaped crystals
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Overview of Gout
• “The king of diseases and the disease of kings”– Hippocrates
• Deposition of monosodium urate crystals in the synovium and periarticular sites creates inflammatory reaction– Painful arthritis/bursitis
negatively birefringent, needle-shaped
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Hallmarks of Gout
• Monoarticular in most cases– 1st MTP joint is the most frequent site of involvement
• Middle-aged men• Familial pre-disposition• Often precipitated by large meal or alcohol intake – ask about recent diet (red meat, fish)
• Acute – develops over hours, resolves in 3-10 days
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Hallmarks of Gout
• Signs & Symptoms: pain, redness, swelling, fever/chills, malaise
• Risk Factors: hypertension, hyperlipidemia, obesity
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Associated Diseases
• Can be secondary to hyperuricemia due to:1. Increased cellular turnover
– e.g. leukemia, multiple myeloma
2. Decreased urate excretion– e.g. chronic renal disease, medications (diuretics,
cyclosporin), toxins (ethanol, lead)
3. Lesch-Nyhan Syndrome– X-linked hypoxanthine-guanine phosphoribosyl-transferase
(HGPRT) deficiency– Severe neurologic symptoms, self-destructive behavior
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Chronic Gout
• Tophi – large accumulations of urate crystals, usually in ear, PIP joints, and elbow
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Chronic Gout
• Tophi are seen as the pale areas of urate crystals surrounded by lymphocytes and macrophages
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Chronic Gout
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Treatment
• Acute gout is treated by reducing pain and inflammation– NSAIDs – 1st line treatment– Colchicine – 2nd line treatment due to potential
toxicity– Corticosteroids – if patient has contraindications
to NSAIDs and colchicine
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Prevention
• For patients suffering from recurrent attacks, prophylactic measures to lower serum urate levels may be initiated following the acute phase
• Lifestyle Modifications:– Decrease dietary protein intake and alcohol consumption– Weight loss
• Medications:– Colchicine– Allopurinol– Probenecid
• Stop thiazide diuretics
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Hallmarks of DDx
1. Chondrocalcinosis (Pseudogout)– Deposition of calcium pyrophosphate dihydrate
crystal deposition creating inflammatory reaction– Clinically similar to gout– Associated with previous joint surgery or
underlying metabolic condition – Differentiate based on synovial fluid analysis
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Pseudogout Crystals
• Positively birefringent, rhomboid-shaped crystals
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Pseudogout on X-ray
Normal KneeKnee with pseudogout (calcified
cartilage) and osteoarthritis
(decreased joint space)
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Hallmarks of DDx
2. Gonococcal Arthritis– Neisseria gonorrhoeae infection– Usually monoarticular • knee, wrist, or small joints of the hand
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Hallmarks of DDx
3. Rheumatoid Arthritis– Autoimmune– Bilateral involvement – PIP & MCP joints, knees– Rheumatoid nodules
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Hallmarks of DDx
4. Osteoarthritis– Degenerative joint disease– Weight-bearing joints– Heberden Nodes at DIP joints– Bouchard Nodes at PIP joints
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Pearls
• Podagra = gout in 1st MTP
• Crystals under polarized light:– Gout = negatively birefringent, needle-shaped– Pseudogout = positively birefringent, rhomboid-
shaped
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Summary
• Patient is started on NSAID therapy and counseled on recurrence rates of gout– 78% have a second attack within 2 years
• Patient states that he will try to start losing weight and cutting back on beer