2. RUINS IN POMPEI, ITALY

8. GOUT & PSEUDOGOUT
By: Dr WAQAR MBBS, MRCP, ASST. PROFESSOR MAAREFA COLLEGE

9. GOUT
1) Definition: It is an inflammatory arthritis, due to deposition of uric acid crystals (in the form of sodium urate), in the joints. In “most” cases, it is associated with high uric acid in blood. Normal uric acid levels in the blood: *Males: upto 7mg/dl * Females: upto 6mg/dl Uric acid is produced from purines during daily cell breakdown, & then excreted in urine.

10. PATHOGENESIS
* In gout, uric acid forms insoluble crystals ( sodium urate) which get deposited in the joint space & periarticular tissues. * These crystals then initiate inflammation which causes joint pain & swelling. *In the long run, crystals may also deposit under the skin, in tendons & in kidneys, causing “tophi” in the skin & tendons , & renal stones & renal insufficiency in the kidneys.

11. GENERAL POINTS ABOUT GOUT
More common in males ( M:F 10:1)
More in obese people
Usually in adulthood ( older males)
Family history often present
6) Hyperuricemia can be asymptomatic (no gout)
7) Gout can occur even with normal uric acid level
* Male a classic
* Obese case, but not
* Above “laazim”

12. CAUSES OF HYPERURICEMIA /GOUT
Overproduction Decreased excretion
of uric acid of uric acid
( much less common) ( most common)
(CAN BE ASSESSED BY COLLECTING 24hrs. URINE)
OVERPRODUCTION:
* High purine synthesis ( due to some enzyme
defect ( Lesh-Nyhan syndrome)
* Leukemias conditions of high cell
* Polycythemia production & so high
* Psoriasis cell destruction

13. Causes of gout(contd.)
* Tumor lysis syndrome ( destruction of cancer cells by chemo.) 2) DECREASED EXCRETION * Idiopathic ( primary gout): In these patients, cause of decreased excretion of uric acid is not known. 90% cases of gout are this ( prim. gout due to underexcretion) * Drugs ( thiazides, low dose Aspirin) * Alcohol * Renal failure * Dehydration

14. POSSIBILITIES WITH HYPERURICEMIA
Acute gout Chronic gout Asymptomatic Renal
stones
ACUTE GOUT
This is an acute attack of severe inflammation in
the affected joint.
Occurs suddenly & lasts for a few days.
Most common joint is 1st metatarsophalyngeal
joint of the foot( big toe)
Severe pain, redness, swelling & hot
Presentation can also be in other joints eg. ankle, knees, wrists, either singly or together

15. acute gout in big toe
acute gout in ankle

16. Acute gout (contd) INVESTIGATIONS: Serum uric acid:
* Usually high but 20% cases can have normal
levels, so it is not 100% diagnostic
2) Joint fluid exam.:
* Shows typical “needle shaped” crystals which
are negatively birefringent under polarised light
microscopy.
This test is diagnostic, but not done frequently. If S/S are suggestive & uric acid is high, treatment is started for the acute attack without fluid test.

17. Synovial fluid under polarised light showing Needle shaped urate crystals

18. 3) Leucocytosis & high ESR ( due to inflamm.)
4) X-Ray:
a) May be normal in acute gout
b) Chronic gout usually shows X-ray changes
What Can Precipitate Acute Attack?
Anything which worsens the hyperuricemia eg:
Infections 2) Any surgery 3) Excess alcohol
4) Excess meat( red meat, liver, kidneys) 5) Sea-
-food ) Drugs ( which?)

19. TREATMENT OF ACUTE GOUT
NSAIDs Steroids Colchicine Non-drug
measures
NSAIDs: Drugs of 1st choice.
* Given in high doses initially
* Indomethacin 50 mg tid, Diclofenac 50mg bd
* Given for 1 -2 wks.
2) Corticosteroids:
* Oral tabs ( prednisone) or intra-articular inj.
* Used if NSAIDs can not be given or not helping
* After few days, taper & stop
* Before giving intra articular, exclude joint infec.

20. Rx of Acute gout (contd)
3) Colchicine: ( tablets) * Another alternative if NSAIDs can’t be given * Best effect if given in the first hrs. * Main side effects: Nausea, diarrhea, abd. pain * Not used too much these days 4) Non-drug measures: * Wt loss * Avoid purine rich foods(red meat, liver, shrimp, certain fish) 5) Avoid alcohol & certain drugs (thiazides, aspirin)

21. REMEMBER !
All the drugs used in the acute attack are analgesics & anti-inflammatory. They do not lower the uric acid levels.
During the acute attack, do not lower the uric acid levels, coz it will worsen the attack.

22. D/D of acute gout
1) Septic artrhitis 2) Reactive arthritis 3) Psoriatic arthritis 4) Pseudogout ( reactive arthritis is a type of arthritis which occurs secondary to infections like urethritis, GI infections) CHRONIC GOUT Recurrent attacks of acute gout can cause chronic pain in the joints. This is called chronic gout & is chatacterised by: * Chronic pain * Joint deformity * Tophi: These are subcutaneous nodules made of uric acid. Found usually in the ear cartilage, fingers, olecranon process & Achilles tendon.

23. tophus in the ear
tophus in the elbow

24. Tophus in Achille’s tendon
tophi in fingers

25. X rays in Chronic gout Erosions wth overhanging edges

26. X-ray showing Tophi

27. X RAY FEATURES OF CHRONIC GOUT
Joint destruction
Bone erosion with overhanging edges
Tophi

28. OTHER EFFECTS OF PERSISTENT
HYPREURICEMIA
Uric acid stones in the urinary tract
Damage to the renal tubules, causing renal failure
( so check urea & creatinine in gout patients)

29. TREATMENT OF CHRONIC GOUT
Uric acid Colchicine Non-drug Lowering drugs measures

30. Uric Acid Lowering Drugs
Drugs which decrease Drugs which increase uric acid production uric acid excretion * Allopurinol * Probenecid * Febuxostat * Uricase Drugs are given lifelong. Aim is to keep uric acid less than 6mg/dl in blood

31. Drugs which decrease uric acid produc.
* Allopurinol, Febuxostat, Uricase
* Allop. & Febux. inhibit the enzyme “xanthine
oxidase”( involved in uric acid synthesis).
* Uricase: Changes uric acid to another substance
2) Drugs which increase uric acid excretion
( uricosuric drugs)
* Probenecid
*Not given if renal excretion of uric acid is already
high, urate stones or urate nephropathy present
* Less effective than Allopurinol

32. Indications of urate lowering therapy
1) If more than 2 acute attacks /yr.
2) Chronic gout (wth/wthout tophi)
3) Uric acid stones or urate nephropathy
If the above criteria are not present, no need
to lower uric acid, even if it is high.
Very Imp. points about urate lowering Rx
Never start during an acute attack. Start at least 2-3 wks after the attack.
2) Give NSAIDs or Colchicine alongwith these drugs,
for a few weeks.

33. Non-Drug Measures for Chronic Gout
Wt loss
Avoid purine rich foods (red meat, liver,
certain fish, shrimps, alcohol)
3) Stop drugs like thiazides, ASA
Management of Asymptomatic
Hyperuricemia
No treatment needed
Treatment is given only if there are renal stones or renal failure due to uric acid nephro-
- pathy.
( give urate lowering drugs in case of no.2)

34. When chemotherapy is given for any cancer
excess breakdown of cells excess uric acid is produced can cause acute gout. This is called “tumor lysis syndrome”. To prevent this, the following steps are taken:
Give Allopurinol or Uricase( urate lowering
drugs)
2) Good hydration (iv fluids) before starting
chemo.)

35. PSEUDOGOUT (CPPD) Another crystal induced arthritis
Crystals of Calcium Pyro Phosphate Dihydrate
Can affect any joint but most commonly wrist, knees & symphysis pubis
Mostly seen in old females( gout more in males)
Can present as acute monoarthritis or oligoarthritis ( like gout) or chr. polyarthritis like R.A./O.A.
Joint fluid shows CPP crystals which are positively birefringent (urate crystals are negatively birefringent) ( CPPD------Positive)

36. Crsytals of Pseudogout are positive bire- -fringent & are of various shapes BUT NOT NEEDLE SHAPED

37. Pseudogout (contd)
7) Often associated wth., hemochromatosis & hyperparathyroidism 8) X-Ray shows linear opacity in the joint cartilage. (X-ray of wrists, symphysis etc) 9) Treatment: * NSAIDs , steroids or colchicine * No role of Allopurinol or probenecid * Colchicine may be given for chronic cases 10) Treat any underlying cause

38. X-Rays in Pseudogout

39. THANK YOU