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HPI • 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 • • • • • • • • 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 • • • • • 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 – – 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 • 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 – – – – 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