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Crystal Arthritides


Gout epi M 40-50 yo; F 65 yo; genetic, environmental
Gout risk factors infxn; trauma; wt loss (esp extreme diets); hosp; dyslipidemia (esp trigs)
Causes of hyperuricemia: overproduction Nutritional (purine consumption, EtOH); hematopoietic, psoriasis, drugs
Causes of hyperuricemia: underexcretion Nutritional (EtOH); renal / vasc; drugs (diuretics); metab / hormones
Sx of hyperuricemia usu asymptomatic / req no tx; look for underlying cause (HTN, metab syn)
uric acid levels influenced by: body habitus, ETOH use, BP, diet & insulin resistance
4 stages of gout hyperuricemia, acute gout, intercritical, chronic
Hyperuricemia = uric acid level: >6.8 mg/dL (levels inc at puberty; higher in men)
High uric acid levels also assoc with: HTN, metab syn, CAD, CKD
Gout: monoarticular manifestn 1st MTP (podagra)> instep > heel > ankle > knee; LE>UE; very painful; self limiting
Gout clinical manifestations very sudden; affected jt = warm, dusky red, swollen, exquisitely tender; systemic signs possible
Gout hard to distinguish from: septic arthritis
Gout: Not useful in dx: serum uric acid, plain films
Gold standard in dx of gout joint aspirate demonstrating uric acid crystals
Tx of choice: acute gout NSAIDs (indomethacin, celecoxib)
Acute gout: other tx colchicine (esp for prophylaxis); c’steroids (oral, IV, intra-art) for pt who cannot take NSAIDs;
Gout tx: never … start a drug to tx elevated uric acid in midst of acute attack; don’t stop prophylactic tx (if already on it) during acute; tx arthritis first, then hyperuricemia (not both at once)
Gout prophylaxis Lifestyle mods (limit offending foods, ETOH; increased fluid intake; wt loss); Eval for provoking meds (diuretics); aspirin, niacin
Indications for gout prophylaxis: 2 or more attacks/yr; erosive dz on plain film; uric acid nephropathy/ nephrolithiasis; chronic polyarticular gout
gout prophylaxis: Pharmacology: colchicine; uricosurics (probenecid); xanthine oxidase inhibitors (allopurinol, Uloric)
uricosurics: MOA decrease urate reabsorption, promotes excretion
xanthine oxidase inhibitors: MOA decrease serum uric acid levels
prior to starting prophylaxis for acute gout: do 24 hr urinary uric acid (<800mg/d = undersecretion; >800mg/d = overproducer)
Acute gout prophylaxis: other limit (3-12 mo); d/c when pt at goal (<6 mg/dL uric a. x 3-6 mo & no attacks); poss fenofibrate, losartan, vit C
genetically engineered uricase = Krystexxa : reduces uric acid & melts tophi; for severe chronic refractory gout
intercritical gout freq inc w/time in untx’d pts; subsequent attacks: less sudden, polyarticular, slower to resolve
Hallmarks of Chronic Tophaceous Gout destructive polyarticular dz; resemble other forms arthritis; multi tophaceous deposits (tophi) (hands, feet, helix of ear); dev about 12 yr after 1st attack; dir rel to uric a. levels; no pain-free intercritical pd
Chronic Tophaceous Gout: tx probenecid, allopurinol, steroids
CPPD Epi true prevalence unk (F > M); if FH, usu presentation <50 yo
CPPD etio idiopathic or associated with primary dz (hyperPTH, hypothyroid, hemochromatosis, hypophosphatemia)
CPPD risk factors trauma (can be minor), MI, CVA, infxn, surg (knee arthroscopy, ?intra-art hyaluronate)
CPPD clin presentation: if sx: If sx, varies: can mimic RA, OA, gout; post-traumatic hemarthrosis; systemic illness (pseudo-PMR); axial dz (c-spine stenosis)
CPPD clin presentation: sudden onset (sim to gout); systemic sx (fever, chills, inc acute phase reactants); acute poss in setting of chronic arthropathy; may worsen OA when both exist
CPPD dx demo crystals in jt fluid; chondrocalcinosis on plain film; CT, MRI and U/S all detect CPPD; do serum Ca, Mg, PO4, alk phos, ferritin, Fe, TIBC
CPPD tx Tx underlying dz; no spec tx for idiopathic dz; poss: NSAIDs / celecoxib; c’steroids (IV, po, intra-art); LD colchicine; hydroxychloroquine; arthrocentesis
BCP crystals have a predilection for: the shoulder
BCP clinical presentations: calcific tendinitis; Milwaukee shoulder; subacromial bursitis; knee & hip poss;
BCP tx NSAIDS, physical therapy
Calcific tendonitis: 4t/5t decades; DM (esp ins-dept); deposits in rotator cuff; often resolve spont
Milwaukee shoulder: rare arthropathy (usu elderly women); rapid rotator cuff & GHJ destn; assoc w/ lg hematomas, bloody synovial fluid
CPPD fx where: large joints (knee, wrist, elbow); chondrocalcinosis; also MCPs, hips, shoulders, ankles
Created by: Abarnard