1. Crystalopathies
Joanna Zalewska

2. Gout
Inflammatory arthritis with crystallization of monosodium urate crystals in joint or soft tissue

3. Classification Asymptomatic hyperuricaemia Acute gout
Recurrent attacks
Chronic tophaceous gout
Urolithasis

4. Risk factors Overall body weight or central obesity
Very rapid weight loss through dieting
Hypertension
Loop and thiazide diuretics
Alcohol

5. Key features in history- acute
First attacks are usually monoarticular with the metatarsophalangeal joint of the great toe
Other joints- wrist, elbow, small joints of hand
Attacks self-limiting after 5-7b days
Onset is often lateat night or in the early morning
Before- surgery, dehydratation, alcohol intake

6. Key features in history- chronic
Polyarticular
Repeated attacks get closer together and become more prolonged
Repeated attacks may result in deformity, reduced rangeof joint movement or chronic pain
Tophi

7. Examination - acute - chronic A hot, swollen, tender joint
Involvement of soft tissues
- chronic
Deformation of joints
Tophi- subcutaneously, in bones and organs- painless (white, creamy discharge)

8. Tests Leucocytosis- acute goat Elevation of ESR and CRP
Serum creatinine
Serum urate
Blood cultures
Synovial fluid- crystals of monosodium urate
Radiographs- unhelpful in early gout, in late- calcification and erosions (head of the first metatarsal)
Ultrasound- synovitis

9. Treatment Asymptomatic hyperuricaemia does not require treatment
Septic arthritis should be considered
Terminate the attack as soo as possible
Ice therapy, NSAIDs, colchicine, glucocorticosteroids

10. NSAIDs Colchicine Indometacin- the traditional NSAIDs
Naproxen in Poland
NSAIDs should be avoided in patients with heart failure, renal insufficiency, history of previous peptic disease
Colchicine
Most patient respond within 18 h
Dose 500 ug 2-4 times daily (diarrhoea)

11. Glucocorticosteroids
Useful in patients who cannot tolerate or not improving with NSAIDs or colchicine
Intra-articular injections are effective in monoarthritis or oligoarthritis
Oral, intramuscular or intarvenous
Prednisolone mg daily for 2 weeks

12. Inhibitors of the enzyme xanthine oxidase- long term treatment
Allopurinol
should not be commenced during an acute attack, but should be introduced 1-2 weeks later
Low dose of colchicine (500 ug) for 6 months following introduction of allopurinol to avoid attacks
The dose should be increased by mg in response to changes in serum urate levels
Side effects- rash, allergic reaction, fever, mucositis, dermatitis
Febuxostat

13. Follow-up
Lifestyle- diet (avoid food with very high purine content as shellfish, sardines, meat, avoid alcohol, drink 2 l of fluid)
Control BP, serum urate, renal function, glucose

14. Calcium pyrophosphate dihydrate disease (CPDD)
Chondrocalcinosis/ pseudogout
Deposition of calcium pyrosphoshate dihydrate crystals
Diagnostic- polarized light microscopy- gold standard
Women age 70

15. Tests Leucocytosis- acute attacks CRP, ESR elevation Creatinine
joint aspiration- rhomboid-shaped crystals under polarized light- the most important
Radiology- medial and lateral menisci of the knee, triangular cartilage of wrist, symphis pubis

16. Treatment NSAIDs Intraarticular injection of glucocorticosteroids
Rest the joint
Low dose of colchicine (1 mg/ day)
Low dose of prednisolone
DMARD
Joint replacement surgery