GOUT

CODILLIA

Definition
Caused by deposition of monosodium urate crystals in
joints and periarticular tissue.
Gout is a result of defect in purine metabolism either due to
rate overproduction and/or impaired excretion of uric acid.
End result> Hyperuricaemia
Three distinct stages:
a)asymptomatic hyperuricemia
b)acute intermittent gout
c)chronic tophaceous gout

Causes
High protein diet (12%)- red meat and seafood
High Alcohol Consumption
Genetic (Familial Juvenile hyperuricemic nephropathy)
Myelo/Lymphoproliferative (Leukaemia and
polycytemia rubra vera)
Metabolic syndrome (DM, Hyperlipidaemia,
hyperparathyroidism)
Renal failure (Uric acid is 100% excreted by kidneys)
Obesity (BMI>35 in male x3 risk)
Medications (Thiazides, niacin, aspirin, cyclosporin)

Clinical manifestation
History of sudden onset of severe pain and swollen joint that
reaches maximum within 6-12 hours.
Throbbing, crushing or excruciating pain with warm, erythema
and tender joint.
Typically affects only one or a few joints commonly the Big toe,
knee and ankle joint.
Tophi around joints
Joint destruction
Renal Disease (Glomerular, Interstitial, Tubular)
Uric Acid Urolithiasis

Diagnosis criteria
Two of the following:
Presence of a clear history of at least 2
attacks of painful joint swelling with
complete resolution within 2 weeks
Presence of thophus
A clear history or observation of a podogra
Rapid response to colchicine within 48 hours
of starting treatment

Acute Intermittent Gout

Initial episode usually follows decades of
asymptomatic hyperuricemia
Characterized by sudden intense pain and
inflammation with warmth, swelling,
erythema last for hours.
Usually begins as monoarticular
involvement with first Metatarsalphalangeal
joint (Big Toe) involve.

Natural course varies

with
improvement/resolution
in days to one to two
weeks
During intercritical
periods joints are
virtually free of
symptoms although
crystal may be found

Podagra
Typically the first
monoarticular
manifestation in 50% of
acute gout.
Recurrent attack is
characteristic with no
symptoms in between
attacks.
Demonstration of MSU
crystals in synovial fluid
or tophus provides
definitive diagnosis

Chronic Tophaceous
Gout
Sodium urate forms white smooth deposit
in skin and around joints
Common sites: Ear lobes, Fingers and
archilles tendon
Can ulcerate
Bony destruction with punched out bone
cyst on x-ray
Often accompanied by renal impairment

Pseudo gout
Cause by deposition of calcium pyrophosphate
crystal
Another form of crystal arthropathy.
Can resemble acute gout
Affects elderly women
Usually affects knees and wrist.
Associated with haemochromotosis,
hyperparathyroidism,Wilsons disease.

Investigation
Synovial fluid Analysis
Long, needle-shaped
crystal
Negatively bifringent
Pseudo gout: weakly
positive bifringent &
rhomboidal crystal.
Serum Urate level
Usually > 0.54 mmol/L

X-ray
Punched out erosion or mouth
bitten appearance - Sclerotic
borders
Tophi - Soft tissue masses at
periarticular area
Intraosseous lesion - rate
crystal seen within the bone
seen as lytic lesion
Preserve joint space
No periarticular osteopenia
Pseudogout: Whit line of
Chondrocalcinosis on X-ray

Anti Gout Drugs

Analgesic
High dose NSAIDs
(Naproxen 500mg bid,
Diclofenac 50mg bid/tds
Indomethacin 50mg bd/tds)
Colchicine - inhibits
microtubule polymerization
(acute attack)
Allopurinol - Decrease uric
acid production (as
prophylaxis)
Probenecid - Increase uric
acid excretion

Non pharmacological
Mx
Dietary advice
Reduce high purine food such as
seafood, red meat, and legumes.
Weight reduction
Reduce alcohol consumption.