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• A 52 yo male presents to his PCP on a Monday
morning with exquisite right knee pain that
started overnight. He spent Sunday tailgating
with friends. He denies trauma or any
previous episodes.
• What else would you like to know?
PMH
• Medical Hx: hypertension, right ACL repair (1980)
• Family Hx: Father has gout, Mother has
hypertension and hyperlipidemia
• Social: Former collegiate football player, divorced
with 3 children, works as a cook at a diner
• What is your differential diagnosis?
DDx
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Gout – primary, secondary
Chrondrocalcinosis (pseudogout)
Infective arthritis (gonococcal)
Septic joint
Rheumatoid arthritis
Osteoarthritis
Meniscal Injury
Ligamentous Injury (ACL, PCL, MCL, LCL)
• What do you want to do next?
Physical Exam
• Height, 6’ 5”; Weight, 300 lbs; BMI, 36
• Vitals: BP 150/90; T 98.9, HR 70, RR 18
• Gen: Patient is cooperative but sitting uncomfortably with
right leg slightly flexed
• HEENT, CV, Respiratory, Abdominal, Neuro, and Psych
Exams: wnl
• Skin: warm, erythematous right anterior knee
• Musculoskeletal: exam limited by patient’s pain tolerance
• What labs do you want to order
and why?
Lab Tests
a) Joint aspiration with synovial fluid analysis
– Can differentiate gout/pseudogout, osteroarthritis,
and septic joint based on number of leukocytes
– Can differentiate gout and pseudogout based on
crystals
b) CBC, ESR, CRP
– rule out septic joint, infective arthritis
c) Serum uric acid level
– limited value, can be high without gout or low during
acute attack
Lab Results
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CBC – normal
ESR – 24 mm/h
CRP – 15 mg/L
Serum Uric Acid – 8.5 mg/dL
Synovial Fluid
– 20,000/mm3 leukocytes
• Osteoarthritis < 2,000, Gout/Pseudogout 5,000-50,000,
Septic Joint > 50,000
– See next slide for microscopic view
Synovial Fluid
• negatively birefringent, needle-shaped crystals
Overview of Gout
• “The king of diseases and the disease of kings”
– Hippocrates
• Deposition of monosodium urate crystals in
the synovium and periarticular sites creates
inflammatory reaction
– Painful arthritis/bursitis
negatively birefringent, needle-shaped
Hallmarks of Gout
• Monoarticular in most cases
– 1st MTP joint is the most frequent site of involvement
• Middle-aged men
• Familial pre-disposition
• Often precipitated by large meal or alcohol intake
– ask about recent diet (red meat, fish)
• Acute – develops over hours, resolves in 3-10
days
Hallmarks of Gout
• Signs & Symptoms: pain, redness, swelling,
fever/chills, malaise
• Risk Factors: hypertension, hyperlipidemia,
obesity
Associated Diseases
• Can be secondary to hyperuricemia due to:
1. Increased cellular turnover
–
e.g. leukemia, multiple myeloma
2. Decreased urate excretion
–
e.g. chronic renal disease, medications (diuretics,
cyclosporin), toxins (ethanol, lead)
3. Lesch-Nyhan Syndrome
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X-linked hypoxanthine-guanine phosphoribosyl-transferase
(HGPRT) deficiency
Severe neurologic symptoms, self-destructive behavior
Chronic Gout
• Tophi – large accumulations of urate crystals,
usually in ear, PIP joints, and elbow
Chronic Gout
• Tophi are seen as the pale areas of urate
crystals surrounded by lymphocytes and
macrophages
Chronic Gout
Treatment
• Acute gout is treated by reducing pain and
inflammation
– NSAIDs – 1st line treatment
– Colchicine – 2nd line treatment due to potential
toxicity
– Corticosteroids – if patient has contraindications
to NSAIDs and colchicine
Prevention
• For patients suffering from recurrent attacks,
prophylactic measures to lower serum urate levels may
be initiated following the acute phase
• Lifestyle Modifications:
– Decrease dietary protein intake and alcohol consumption
– Weight loss
• Medications:
– Colchicine
– Allopurinol
– Probenecid
• Stop thiazide diuretics
Hallmarks of DDx
1. Chondrocalcinosis (Pseudogout)
– Deposition of calcium pyrophosphate dihydrate
crystal deposition creating inflammatory reaction
– Clinically similar to gout
– Associated with previous joint surgery or
underlying metabolic condition
– Differentiate based on synovial fluid analysis
Pseudogout Crystals
• Positively birefringent, rhomboid-shaped crystals
Pseudogout on X-ray
Normal Knee
Knee with pseudogout (calcified
cartilage) and osteoarthritis
(decreased joint space)
Hallmarks of DDx
2. Gonococcal Arthritis
– Neisseria gonorrhoeae infection
– Usually monoarticular
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knee, wrist, or small joints of the hand
Hallmarks of DDx
3. Rheumatoid Arthritis
– Autoimmune
– Bilateral involvement – PIP & MCP joints, knees
– Rheumatoid nodules
Hallmarks of DDx
4. Osteoarthritis
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Degenerative joint disease
Weight-bearing joints
Heberden Nodes at DIP joints
Bouchard Nodes at PIP joints
Pearls
• Podagra = gout in 1st MTP
• Crystals under polarized light:
– Gout = negatively birefringent, needle-shaped
– Pseudogout = positively birefringent, rhomboidshaped
Summary
• Patient is started on NSAID therapy and
counseled on recurrence rates of gout
– 78% have a second attack within 2 years
• Patient states that he will try to start losing
weight and cutting back on beer