27 April 2009

Crystalline Arthropathies



Crystalline Arthropathies
Presentation by: Walter Eisenhauer MMSc, PA-C

Gout

* The Disease of Kings, The King of Diseases
o Predominately disease of adult men
o Females spared until postmenopause
o Uric Acid by product of Purine metabolism
o 10% of those with gout overproduce- the remaining 90% are underexcretors
* Urates circulate in plasma mainly in unbound form
o Referred to as urate pool
o Pool increases as Uric acid levels increase
o Excreted by two mechanisms
+ Renal
+ Bacterial oxidation in the gut
* Total Body urate Pool 1200 mg males/600 mg females
o 85% denovo synthesis
o 15% dietary intake of purines
o Purine restricted diet may only decrease serum urate level by 1-1.2 mg/dl
Urate – complete filtration

+ Presecretory tubular resorption 99%
+ Tubular excretion 50%
+ Post secretory resorption 80%
+ Excretion of 10% filtered load (600 mg/day)
+ Additional 1/3 excreted by pancreatic and intestinal juices
* Two Main Classifications
o Overproducers
o Under Excreters
* Overproducers
o 10%
o Primary
+ Idiopathic
+ Enzyme abnormalities in purine metabolism
o Secondary
+ Excessive dietary uptake
+ Myeloproliferative disorders
+ Severe muscle exertion
* Decreased excretion- 90%
o Primary Vs Secondary
+ Primary
# Unidentified defect in tubular secretion ( up to 40 % less)

* Secondary
+ Renal insufficiency
+ Diuretics
+ Low dose ASA
+ Cyclosporine
+ Ethambutol
+ Lead toxicity
+ Saturnine gout due to nephropathy
+ DKA
+ Starvation
+ Ketosis
+ Ethanol
+ Lactic acidosis
+ Predisposing illness- HTN, DM etc
+ Combined ETOH/G6PD deficiency
* Urate Pool substantially enlarged in Gout
o Non Tophaceous- 2-4gm
o Tophaceous 30 gm or more
* Urate solubility
o At physiologic ph 99% as urate not uric acid
o Soluability at 37degrees is 7.0 vs 30 degrees is 4.5 mg/dl
o Intrarticular temp at the knee is 33 degrees- ankle 29 degrees
* Acute Gout clinical features
o Males 4th-6th decade
o Consider enzyme abnormality if before 60
o 38% with normal uric acid
o Monoarticular 85-90%
o Podagra in 50%, ultimately 90%
o Primarily lower extremity joints
o Precipitated by
+ Surgery
+ Trauma
+ Febrile Illness
+ Excessive eating or ETOH consumption
* Systemic symptoms in polyarticular forms
o Fever
o Chills
o Elevated WBC/ESR
* Spontaneous resolution over days to weeks
* Females older, post menopausal
* Intercritical gout
o 7-10% only experience initial attack
o 62% with second attack within 1 year
o Majority with attack within 6-24 months
o Ultimately attacks more frequent and polyarticular

* Tophaceous Gout
o 3-21% develop
o Average 11.6 years after initial episode
o Typically ear, elbows, fingers, Achilles tendons but may appear anywhere
o Synovial tophi can lead to bone erosions
* Transplant Gout
o Primarily related to cyclosporine
o Acute gout often after one year
o Tophaceous gout within 5 years
o 13% decrease in ADL’s secondary to gout
* Renal Manifestations
o Stones presenting manifestation of up to 1/3
o Gouty Nephropathy-inter parenchymal deposits of monosodium urate crystals causing inflammation and scarring
o Acute Uric Acid Nephropathy caused by obstruction of tubules with uric acid crystals

* Diagnosis
o Can not make dx with blood studies
o Demonstrate crystals in synovial fluid
o Presence of tophi
o Presumptive on basis of clinical presentation
o Strongly negative birefringent, needle shaped, often intracellular crystals

* Xray
o Punched out lesions
o Asymmetric nodular soft tissue swelling
o Joint space narrowing- often asymmetric

* Treatment

Pseudogout

* CPPD- Calcium Pyrophosphate Dihydrate
* Chondrocalcinosis when calcium in cartilage
* Mimics presentation of Gout attacks
* Treat with NSAIDS
* Rule out Hyperparathyroidism

Crystalline Arthropathies.ppt

0 comments:

All links posted here are collected from various websites. No video or powerpoint files are uploaded on this blog. If you are the original author and do not wish to display your content on this blog please Email me anandkumarreddy at gmail dot com I will remove it. The contents of this blog are meant for educational purpose and not for commercial use. If you use any content give due credit to the original author.

This site uses cookies from Google to deliver its services, to personalise ads and to analyse traffic. Information about your use of this site is shared with Google. By using this site, you agree to its use of cookies.

  © Blogger templates Newspaper III by Ourblogtemplates.com 2008

Back to TOP