Download Compendius Review on Gout

KUSHAGRA , MS IV, MAMC, DELHI
DR. GILLIAN LIEBERMAN, M.D.
AUGUST 23, 2010
Kushagra, MAMC MS IV
Gillian Lieberman, MD
 Definition
 Epidemiology
 Pathophysiology,
Etiology and Risk Factors
 Stages and Clinical Features
 Associated Co-Morbidities
 Common Sites and Distribution
 Patient Discussion
 Classical Findings
 Differential Diagnosis
 Menu of Imaging Studies
 Management and Preventive Measures
Kushagra, MAMC MS IV
Gillian Lieberman, MD
 GOUT
is a form of peripheral arthritis resulting
from the deposition of monosodium urate crystals
secondary to hyperuricemia.
 The
metatarsal- phalangeal joint at the base of the
big toe is the most
common affected.( Also
known as PODAGRA).
emedicine.medscape.com
Kushagra, MAMC MS IV
Gillian Lieberman, MD

Gout is a common systemic metabolic disease,
affecting more than 1% of the population.

It is the most common inflammatory arthritis, afflicting
1 or more joints in men older than 40 years of age.

Typically occurs in middle aged or elderly males (90%
of cases are in males).

Prevalence in the United States: 1.6 to 13.6 per 1000.
Kushagra, MAMC MS IV
Gillian Lieberman, MD

Gout can be broadly classified into 2 types:
PRIMARY
SECONDARY

Gout is called Primary when no identifiable disease
causing the hyperuricemia can be found.

Primary Gout occurs in Majority of the cases.

Secondary Gout, which is less common, occurs due to
some underlying disease.
Kushagra, MAMC MS IV
Gillian Lieberman, MD
 Causes
can be broadly classified into :
INCREASED URIC ACID PRODUCTION
(5%-10% of patients)
DECREASED URIC ACID EXCRETION
(90%-100% of patients)
Kushagra, MAMC MS IV
Gillian Lieberman, MD
INCREASED URIC ACID PRODUCTION
(5%-10% of patients)
 Genetic



enzymatic defects
Hypoxanthine-guanine phosphoribosyl transferase
deficiency
glucose-6-phosphatase deficiency
5-phosphoribosyl-1-pyrophosphate synthetase
overactivity
Kushagra, MAMC MS IV
Gillian Lieberman, MD
INCREASED URIC ACID PRODUCTION
(5%-10% of patients)
Acquired causes
 Dietary indiscretions: excessive purine diet


Obesity
Increased tissue turnover—tumors, lympho-proliferative
disorders

Vigorous muscle exertion causing increased turnover of ATP

Alcohol-induced turnover of ATP

Chemotherapy
Kushagra, MAMC MS IV
Gillian Lieberman, MD
DECREASED URIC ACID EXCRETION (90%100% of patients)
 Genetic causes



Down syndrome
Polycystic kidney diseases
Acquired causes
Diminished renal function
 Inhibition of tubular urate secretion:
competitive anions (keto-acidosis
and lactic acidosis)

Kushagra, MAMC MS IV
Gillian Lieberman, MD
DECREASED URIC ACID EXCRETION (90%100% of patients)

Acquired causes

Enhanced tubular urate reabsorption:

Dehydration

Starvation

Insulin resistance (metabolic syndrome)

Medications:

Low-dose aspirin

Thiazide and diuretics

Ethambutol

Niacin

Lead nephropathy
Kushagra, MAMC MS IV
Gillian Lieberman, MD

Humans do not express the enzyme urate oxidase
(uricase), because of a mutation during evolution of the
uricase gene, which converts urate to the more soluble
and easily excreted compound allantoin.
Less Soluble
More Soluble
Kushagra, MAMC MS IV
Gillian Lieberman, MD

Among mammals, only humans and other primate
species excrete uric acid as the end product of
purine metabolism.

Uric acid is a weak organic acid that exists mainly
as the urate ion at pH >5.75 and as the un-ionized
uric acid form at more acidic (lower) pH levels.

Thus, the urate form predominates in all
extracellular fluids, including serum, in which
physiological pH is 7.4. In urine, which is usually
acidic, the un-ionized uric acid form predominates.
Kushagra, MAMC MS IV
Gillian Lieberman, MD
 When
overproduction or underexcretion of uric
acid occurs, the serum urate (SU)
concentration may exceed the solubility of
urate (a concentration approximately >6.8mg/dl),
and supersaturation of urate in the serum (and
other extracellular spaces results. This state, called
hyperuricemia, imparts a risk of crystal deposition
of urate in tissues from the supersaturated fluids.
Kushagra, MAMC MS IV
Gillian Lieberman, MD
1.
ASYMPTOMATIC STAGE
2.
ACUTE GOUTY ARTHRITIS
3.
INTER-CRITICAL GOUT
4.
CHRONIC TOPHACEOUS GOUT
Kushagra, MAMC MS IV
Gillian Lieberman, MD



ACUTE GOUTY ARTHRITIS
90% of attacks involve a single joint with severe
pain, redness and swelling.
Mostly involving the lower extremity, usually
the first metatarsal-phalangeal joint.(>50%)
beliefnet.com
qwickstep.com
Kushagra, MAMC MS IV
Gillian Lieberman, MD

INTER-CRITICAL GOUT

These are asymptomatic intervals between acute
attacks most common early in disease
progression.

This pattern is quite uncommon in other arthritic
disorders and alone is very suggestive of gout.
Kushagra, MAMC MS IV
Gillian Lieberman, MD
 CHRONIC
TOPHACEOUS GOUT
 The tophus is the pathognomonic lesion of gout
and is essentially a foreign body granuloma.
 Seen in the external ear and pressure points over
the elbows, hands, feet, knees, and forearms.
hopkins-arthritis.org
cedar-sinai.edu
Kushagra, MAMC MS IV
Gillian Lieberman, MD
 PAIN

Rapid onset and progression.

Worst pain that the person has ever endured.

Associated with warmth, redness, and swelling of the
affected joint.

Systemic symptoms and signs of fatigue, fever and
chills may accompany.

The first episode of gouty arthritis often begins at
night.
Kushagra, MAMC MS IV
Gillian Lieberman, MD
 GOUTY
NEPHROPATHY
 Two renal syndromes are associated with
hyperuricemia:
 acute urate nephropathy and
 uric acid urolithiasis.
.
kidney-stone-treatment.blogspot.com
Uric acid stone
lithostat.com
Calcium oxalate stones
Kushagra, MAMC MS IV
Gillian Lieberman, MD
 Patients
also have an increased incidence of
calcium oxalate stones because urate crystals serve
as nidus for calcium stone formation.

Isosthenuria (inability to concentrate
urine), pyelonephritis and proteinuria are other
renal manifestations.
Kushagra, MAMC MS IV
Gillian Lieberman, MD
 BONE

EROSIONS
Deposits of urate crystals (tophi) form along the margins of the
articular cortex and may erode the underlying bone, producing small,
sharply marginated, punched-out defects at the joint margins of the
small bones of the hand and foot.
appliedradiology.com
Frontal and Lateral view of the Index finger showing pressure erosion
On the volar surface of middle phalanx by soft tissue mass.
Large soft tissue mass associated
With osteolysis of first MTP joint.
Kushagra, MAMC MS IV
Gillian Lieberman, MD
 SOFT
TISSUE ABNORMALITIES
Tophi (Soft Lumpy Nodule) can be seen radiologically
most commonly at:
 First metatarsophalangeal joint
 The ear
 Olecranon bursa and
 The Achilles tendon

Ear Tophi
wikipedia.org
wikipedia.org
Tophi on Knee
Kushagra, MAMC MS IV
Gillian Lieberman, MD
BONE MINERALISATION
 The bone mineral density is preserved until late in the
disease.


Extensive osteoporosis is not a feature of
gout.

The presence of normal mineralization may help
differentiate this condition from rheumatoid arthritis.

The reason for the presence of normal mineralization is
that the duration of the attack is too short to allow the
development of osteoporosis of disuse as is seen in
rheumatoid arthritis.
Kushagra, MAMC MS IV
Gillian Lieberman, MD
 CHONDROCALCINOSIS
Five percent of patients with gout have cartilage
calcification or chondrocalcinosis.
 Chondrocalcinosis manifests because they have a
predisposition for calcium pyrophosphate
dihydrate crystal deposition disease (CPPD).
 ARTICULAR ABNOMALITIES
 The joint space is well preserved until late in the
course of the disease.
 The presence of relatively normal joint space and
preservation of the articular cartilage with
extensive erosions is a distinctive radiographic
feature of gout.
 BURSITIS

Kushagra, MAMC MS IV
Gillian Lieberman, MD
 CARDIOVASCULAR
DISEASES:
HYPERTENSION
 MYOCARDIAL INFARCTION
 STROKE

 METABOLIC
SYNDROME
 OBESITY
 HYPERTENSION
 HYPERLIPIDEMIA
 INSULIN
RESISTANCE
Kushagra, MAMC MS IV
Gillian Lieberman, MD
sedico.net
Kushagra, MAMC MS IV
Gillian Lieberman, MD
 Lower
 Small
extremity > upper extremity
joints > large joints
 Random
distribution in hands (helpful diagnostic
distinction)
 First

MTP most common (podagra)
Asymmetric distribution is characteristic of gouty
arthritis.
Kushagra, MAMC MS IV
Gillian Lieberman, MD
Joint
gentili.net
Freque
ncy
DIP
++
1st IP
++
2nd-5th PIP
++
1st MCP
++
2nd-5th MCP
++
1st CMC
+++
2-5 CMC
+++
Midcarpal
+++
Radiocarpal
++
Radioulnar
++
Kushagra, MAMC MS IV
Gillian Lieberman, MD

81 year old lady came to the OPD with soft lumpy
nodules over hands.

She was having difficulty in extending fingers of the
Right hand.

She had episodes of pain, redness and swelling in the
Right hand since past 10 years. The left hand got
involved over a period of time.

Denies any recent fever, fatigue or weight loss

She is having nodules at the right elbow and 1st MTP in
both feet.
Kushagra, MAMC MS IV
Gillian Lieberman, MD
Extensively calcified
tophi and bony destructive
changes are seen involving
the DIP and PIP joints of
the 2nd, 3rd and 4th digits.

Erosions
are seen at the
base of the 1st metacarpal,
head of the 2nd metacarpal
and ulnar styloid process.
PACS
BIDMC
Kushagra, MAMC MS IV
Gillian Lieberman, MD
Patient
is unable to
extend the fingers of her
Right hand.
Erosions
are noted in the
right hand at the head of
the 5th metacarpal and
base of the 1st metacarpal
bones.
PACS
BIDMC
Kushagra, MAMC MS IV
Gillian Lieberman, MD
Bony
destruction with
overhanging cortical edges
are noted along the lateral
condyle.
Adjacent
subchondral
cysts and osseous
fragments are noted within
this region.
PACS
Kushagra, MAMC MS IV
Gillian Lieberman, MD
Extensive
destructive
changes of all digits
involving the MTP, PIP
and DIP joints of the
right feet are noted with
extensively calcified
large tophi.
PACS
BIDMC
Kushagra, MAMC MS IV
Gillian Lieberman, MD
Tarsometatarsal
and
ankle joint tophi and bony
destruction can be seen.
Marked
bony destruction
can be noted on MTP, DIP
and PIP.
PACS
BIDMC
Kushagra, MAMC MS IV
Gillian Lieberman, MD
Extensive
destructive
changes of all digits
involving the MTP, PIP and
DIP joints of the left feet are
noted with extensively
calcified large tophi.
There
are medial
subluxations of the 2nd and
3rd metatarsal phalangeal
joints of the left foot.
PACS
BIDMC
Kushagra, MAMC MS IV
Gillian Lieberman, MD
Tarsometatarsal
and
ankle joint tophi and
bony destruction can be
seen.
Marked
bony
destruction can be noted
on MTP, DIP and PIP.
PACS
BIDMC
Kushagra, MAMC MS IV
Gillian Lieberman, MD
 Lateral
radiograph of the
elbow

appliedradiology.com
Amorphous calcified
tophaceous deposits in
the olecranon bursa.
Kushagra, MAMC MS IV
Gillian Lieberman, MD
 Gout-
Olecranon
Bursitis.
learningradiology.com

There is soft tissue
swelling in the
olecranon bursa (white
arrow)
a finding suggestive of
gout.

There are also erosions
(blue arrows) around
the elbow joint.

There is no
periarticular
demineralization.
Kushagra, MAMC MS IV
Gillian Lieberman, MD
 Frontal
view
of the index
finger

appliedradiology.com
Well-defined
subarticular cyst
in this patient
who has gouty
arthritis.
Kushagra, MAMC MS IV
Gillian Lieberman, MD
 Frontal
Radiograph of
the foot

appliedradiology.com
Erosion with
Typical overhanging
edge at the head of
the first metatarsal.
Kushagra, MAMC MS IV
Gillian Lieberman, MD
 Lateral
radiograph
of the ankle
appliedradiology.com

Thickened Achilles
tendon due to deposition
of urate crystals.

The integrity of the
Achilles tendon is
apparently maintained.
Kushagra, MAMC MS IV
Gillian Lieberman, MD

CPPD (Pseudo gout)

Psoriasis

Rheumatoid arthritis

Amyloidosis

Joint infection

Osteoarthritis

Xanthomatosis
Kushagra, MAMC MS IV
Gillian Lieberman, MD
GOUT
PSEUDOGOUT
Ratio of men to women
7:1
1:1.5
Age group affected
Men >40 years old
Postmenopausal women
Elderly
Serum urate
Elevated
Normal
Joints involved
First MTP
joint, knees, wrists,
fingers, olecranon bursa
Knees, wrists, ankles
Involvement of 1st MTP
Common
Rare
Tophi
Present
Rare tophi-like
deposits
Radiographic
findings
Erosions with
overhanging edges
Chondrocalcinosis
Crystals
Needle-shaped, strong
negative birefringence
Rhomboid-shaped,
weakly positive
birefringence
Kushagra, MAMC MS IV
Gillian Lieberman, MD
 PSORIASIS
progressive joint-space destruction
 paravertebral ossification
 sacroiliac joint involvement

 RHEUMATOID
ARTHRITIS
presence of symmetric distribution
 early joint-space narrowing
 osteopenia.

Kushagra, MAMC MS IV
Gillian Lieberman, MD
JOINT INFECTION
 rapid destruction of joint space


loss of the lamina dura (articular cortex) over a
continuous segment of the bone.
AMYLOIDOSIS
 Bilateral and symmetric


Periarticular osteopenia is frequent.
Kushagra, MAMC MS IV
Gillian Lieberman, MD
XANTHOMATOSIS
 foci of soft-tissue deposition of cholesterol and lipid
products.


Laboratory work-up for differentiation
OSTEOARTHRITIS
 elderly women


symmetric distribution

Erosion of the joint space
Kushagra, MAMC MS IV
Gillian Lieberman, MD
 X-RAY
FILM
 COMPUTED
TOMOGRAPHY (CT) SCANS
 MAGNETIC
RESONANCE IMAGING (MRI)
 ULTRA
SOUND
Kushagra, MAMC MS IV
Gillian Lieberman, MD
normal mineralization
 joint space preservation
 sharply marginated erosions with sclerotic
borders
 overhanging edges
 asymmetric polyarticular distribution

 LIMITATIONS

Indicates the chronicity 6-8 years after the
initial attack
Kushagra, MAMC MS IV
Gillian Lieberman, MD

reveal MSU deposits in vitro as well as within the
knee joint

readily diagnose stones of the urinary tract not
visible on conventional radiographs
Kushagra, MAMC MS IV
Gillian Lieberman, MD

detects early subclinical tophaceous deposits

determining the extent of disease in tophaceous
gout

provides information regarding the patterns
of deposition and spread of MSU crystals.
Kushagra, MAMC MS IV
Gillian Lieberman, MD

more reliable, noninvasive method for diagnosis

can detect deposition of MSU crystals on
cartilaginous surfaces, as well as tophaceous
material and typical erosions
Kushagra, MAMC MS IV
Gillian Lieberman, MD
 ASYMPTOMATIC
 Usually
HYPERURICEMIA
requires No treatment except in:
Elevated Serum Uric acid level
 Positive Family history of tophaceous gout

 Treated
with Allopurinol under closed medical
observation
Kushagra, MAMC MS IV
Gillian Lieberman, MD

ACUTE GOUTY ARTHRITIS

Joint immobilization

Colchicines

Nonsteroidal anti-inflammatory agents(NSAIDs)

Corticosteroids

Uricosuric agents and allopurinol are of no value in
treatment of the acute attack.
Kushagra, MAMC MS IV
Gillian Lieberman, MD
 INTER-CRITICAL
GOUT (INTERVAL PERIOD)
PREVENTIVE MEASURES
Kushagra, MAMC MS IV
Gillian Lieberman, MD
 CHRONIC
GOUTY ARTHRITIS
 Allopurinol
is the drug of choice
 Uricosuric
drugs, such as Probenecid and
Sulfinpyrazone, may also be used
 In
selected patients, large deforming tophi may
be excised surgically
Kushagra, MAMC MS IV
Gillian Lieberman, MD
 DR.
GILLIAN LIEBERMAN
 GRAHAM
 DR.
FRANKEL
VERONICA FERNANDES
 DIKSHITA
DUBEY
 SNEHANSH
 TEJESHWAR
ROY CHAUDHARY
SINGH JUGPAL
Kushagra, MAMC MS IV
Gillian Lieberman, MD

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







Brant WE, Helms CA. Fundamentals of Diagnostic Radiology. 2nd ed. 1999
Lippincott Williams & Wilkins Philadelphia
Ruddy et al. Kelley's Textbook of Rheumatology. 6th ed. 2001 W. B. Saunders
Company
Weissleder R, Wittenberg J, Harisinghani MG. The Primer of Diagnostic Imaging.
3rd ed. 2003 Mosby, Inc. Philadelphia
"Diagnostic Radiology/Musculoskeletal Imaging/Joint Disorders/Gout Wikibooks, Collection of Open-content Textbooks." Wikibooks. Web. 19 Aug.
2010.
<http://en.wikibooks.org/wiki/Diagnostic_Radiology/Musculoskeletal_Imaging/Jo
int_Disorders/Gout>.
Ferguson, Mark. Gout. Print.
"Gout." Dr. Amilcare Gentili's Radiology Education Publications on the Internet"
Web. 18 Aug. 2010. <http://www.gentili.net/Hand/gout.htm>.
Schlesinger, Naomi. "Diagnosis of Gout: Clinical, Laboratory, and Radiologic
Findings." AJMC - American Journal of Managed Care. Web. 20 Aug. 2010.
<http://www.ajmc.com/media/pdf/A141_Diagnosis>.
Smelser, Christopher D. "Gout." EMedicine - Medical Reference. Web. 19 Aug.
2010. <http://emedicine.medscape.com/>.
Web. 20 Aug. 2010. <http://www.gout.com/causes-triggers.aspx>.
Zayas, Vanessa M. "Gout: The Radiology and the Clinical Manifestations."
Applied Radiology Online - The Journal of Practical Medical Imaging and
Management. Web. 16 Aug. 2010. <http://www.appliedradiology.com>