CASE REPORT

ACUTE EXACERBATION
GOUT ARTHRITIS
Marlina Yanti
Hermalina Sabru
A.Ika Sari Mutmainna
Tsabitha Hauro Narundana

Resident
dr. Zainal Abidin

DEPARTMENT OF INTERNA
RHEUMATOLOGY
2018
 PATIENT IDENTITY

Name : Mr BR
Age : 75th years old
Address : Makassar
MR : 862205
Date of Admission : 8/11/2018

Case Report
2
 HISTORY TAKING

Chief complaint: Pain

Further anamnesis:
A male patient of 55 year old came to Wahidin
Sudirohusodo Hospital with complaint of pain and swelling
at his left and right ankle that had been felt since 1 week
ago, and getting worse for 3 days ago (VAS: 4/10). Pain
especially felt during walking and reduced when rest. The
pain getting heavier in midnight almost every day. The
lesion looked red, feel warm and pain when touched.
Before the exacerbation, patient ate some red meat.
patient does not consume alcohol. No fever. No loss of
appetite

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 HISTORY TAKING

 There is a history of high purin consumption such as

seafood and red meat
 History of pain and swollen at the same location during the
last 2 years, took medicine bought from physician, pain
reduced with the medicine but relapse when the patient
consume high purin .
 History of tuberculosis (+) on treatment first month
 Defecation normal, urination normal, there is no sand found
in the urine
 There is no history of hypertension, diabetes mellitus,
obesity, heart disease, and renal disease
 There is no history of family members with a same complain
 There is no history of trauma
 PHYSICAL EXAMINATION

General Description
General condition : Moderate illness
Nutrition : Normoweight
Height : 159 cm
Weight : 58 kg
BMI : 22.94 kg/m2

Vital Signs
Awareness : Compos mentis (GCS 15)
Blood pressure : 140/80 mmHg
Heart rate : 84 x/minutes, regular
Respiratory rate : 20 x/minutes
Temperature : 36,7 °C
VAS : 4/10

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 PHYSICAL EXAMINATION

Head and neck

 Head : Normocephal, hair not easy to remove

 Face : Normal (simetric)
 Eyes : Pupils isochor, conjunctiva anemic (+), scleral
icterus (-)
 Ear : No abnormalities, otorrhea (-)
 Nose : No abnormalities, secret (-)
 Oral cavity : No abnormalities
 Throat : Tonsil T1-T1, pharyngeal hyperemia (-)
 PHYSICAL EXAMINATION

 Lung
Inspection : Symmetrical left and right
Palpation : Vocal fremitus simetris
Percussion : Sonor
Auscultation : Vesicular breathing sounds, wheezing (-), ronchi (-)

 Heart
Inspection : Ictus cordis not seen
Palpation : Ictus cordis palpable at ICS V line midclavicularis
Percussion : Dull, left heart border linea midclavicularis sinistra
Auscultation : Heart sound I / II regular, no murmur

 Abdomen
Inspection : Normal
Auscultation : Bowel peristalsis (+) normal
Palpation : Liver and spleen not palpable
 RHEUMATOLOGICAL STATUS

Gait : Antalgic gait, dependent ambulation

Arm : normal
Leg :
 Ankle dextra
Tophus (-), calor (+), rubor (+), dolor (+), tenderness (+),
limited ROM, deformity (-)
 ankle sinistra
Tophus (-), calor (+), rubor (+), dolor (+), tenderness (+),
limited ROM.
Spine : No examination was done.
 LABORATORY FINDINGS

Hematology routine December, 25th, 2018

Leukosit 24.20/ uL 4000-11.000/µL
Eritrosit 2.64 x 106 / uL 4.5-5.5 x 106 / µL
Hemoglobin 7.3 g/dL 13.0 – 16.0 g/dL
Hematokrit 21.1 % 40-50 %
Trombosit 235.000 / µL 150.000-450.000 / µL
MCV 79.9 fL 80-100 fL
MCH 27.7 pg 27-34 pg
MCHC 34.6 g/dl 31-36 g/dl
Neutrofil 20.83 % 50-70%
Limfosit 1,59 % 20-40%
Monosit 1.64 % 2-8%
Eosinofil 0.12 % 2-3 %
Basofil 0.02 % 0-1 %
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 LABORATORY FINDING

Blood Chemistry November 8 th, 2018

Blood Glucose 125 140
Ureum 17 mg/dL 0-53 mg/dL
Creatinine 0.71 mg/dL 0.6-1.3
SGOT 14 U/L <35U/L
SGPT 12 U/L <45U/L
Uric Acid 15.2 3,4 - 7
 PROBLEM LIST
Planning
Assessment Plannning Therapy
Diagnosis
Acute in chronic exacerbation -x ray ankle • Diet purin, protein 0,8
gout arthritis gr/kgBW/day
• Colchicine 0,5 g/6h/oral
based on: • Meloxicam 15mg/24h/oral
History of pain and swelling on • Intraarticular injection
right and left ankle for 2 years
history of high purin consumption
Lab:
-uric acid : 15.2 mg/dl
Tuberculosis on treatment Continue medication

based on:
History of tuberculosis (+) on
treatment first month

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DISCUSSION
 DEFINITION

Gouty arthritis is a inflammatory disease initially

triggered by the d e p o s i ti o n of m o no so d i u m
u r a t e c ry s t a l s into the joint space, developing
into an inflammatory cascade resulting in the
secetion of several proinflammator cytokines and
neutrophil recruitment into the joint.

15
 EPIDEMIOLOGY
 Gout is a relatively common inflammatory condition,
affecting an estimated 8 . 3 m i l l i o n individuals in the United
States by 2008. It is more prevalent in m e n than women at
a 4:1.

 Prevalence also increases dramatically with a g e , with

almost 12% of males aged 70-79 years affected compared
with <3% in men younger than 50 years

 Gout frequently presents with multiple comorbidities:

h y p e r t e n s i o n in up to 58% of gouty patients, d y s l i p i d e m i a
in 45%, both hypertension and a lipid disorder in 33%, and
d i a b e t e s m e l l i t u s in 20%.

 The most frequently filled prescriptions amongst these

patients include a n t i h y p e r t e n s i v e d r u g s , s t a t i n s a n d16
RISK FACTORS
 PATHOGENESIS
Ribose 5-P + ATP
(Purines-edogeneous ad dietary)
PRPP synthetase

5-Phosphoribosyl-1-pyrophosphate (PRPP)

Glutamine

Inosine
 Urate biosythesis HPRT

Hypoxathine
Xanthine oxidase

Xathine
Xanthine oxidase

Uric acid 18
 PATHOGENESIS
 Pathogenesis of hypericeamia

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PATHOGENESIS GOUT ARTRITIS
 STAGING OF GOUT

1. Asymptomatic tissue deposition

2. Acute Gouty Arthritis
3. Intercritical Gout
4. Chronic Articular and Tophaceous Gout

GUIDELINE FOR GOUT MANAGEMENT - SLIDESHARE

 1. ASYMPTOMATIC TISSUE
DEPOSITION
Patients have hyperuricemia and asymptomatic
deposition of crystals in tissues but no overt
symptoms.
Starting in adolescence in men and
postmenopausal in women
 2. ACUTE GOUTY ARTHRITIS

Often involve of a single joint or multiple joints in the

lower extremities: first metatarsophalangeal (podagra;
50% of people with gout), midtarsal, ankle and knee
joints
Characterized by pain, erythema, swelling and
warmth. Desquamation of skin may be associated.
Can even cause fever and leukocytosis
Maximal severity reached within 12-24 hours
Even without treatment, attacks resolve within days to
several weeks
ACUTE GOUT OF THE LEFT Acute gout with drainage of urate
FIRST M E TATA R S A L – from third toe mimicking acute
PHALANGEAL JOINT, ALSO infectious process
K N O W N A S P O D AG RA
 3. INTERCRITICAL GOUT
 Period between acute flares, patient continues to have
hyperuricemia.
 Intervals between attacks are variable.
 Duration attacks often becomes shorter as disease
progresses. Attacks are frequently more prolonged and
debilitating, polyarticular and associated with fever.
 4. CHRONIC ARTICULAR AND
TOPHACEOUS GOUT
 Typically occurs after years of uncontrolled gout/ hyper
uricemia.
 Characterized by the presence of tophaceous deposits
(tophi) in the synovium and other tissues
 It can closely mimic other forms of chronic inflammatory
arthritis (e.g. RA).
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DIAGNOSIS
Scoring Algorithm for Gout According to 2014
EULAR/ACR Preliminary Classification Criteria

The treshold value for classifying a case as gout is

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 DEFINITIVE DIAGNOSIS

 The definitive diagnosis of

gout requires aspiration
and examination of
synovial fluid from the
affected joint ( or material
from a tofus ) using a
polarized light microscopy
to confirm the presence of
needle- shaped
monosodium urate cystal
MANAGEMENT THERAPY
 NON PHARMACOLOGICAL
NON PHARMACOLOGICAL

Reduce body weight until ideal

Lower purin diet
Rest the joint
Hydration with 2L water/day
Avoid drugs that causes increase urid
acid level
PHARMACOLOGICAL

DIAGNOSIS, TREATMENT, AND PREVENTION OF GOUT. 201

DIAGNOSIS, TREATMENT, AND PREVENTION OF GOUT. 2014;
 MANAGEMENT
 EU LA R R eco mm en da t io n f or t h e ma n a g em en t o f f la r es in pa t ie n t w i t h go u t
Treat as early as possible

Education about the disease

Liestyle advide
Renal Sscreenig for comorbidities annd current medications Presence of strong
failure CYP3A4 or p-glcoprotei
inhibitors

Therapeutic options
depending on severity,
Avoid colchicine and NSAIDs number of affected joints Avoid colchicine
ad duration of attack

Oral Combination
Colchicine NSAIDs corticosteroids therapies (for
IA
(1 mg folowwed (classic or coxibs (prednnisolone istance colchicine
Injection of
by 0.5 mg after + PPI if 30-35 mg for 5 + NSAIDs or
corticosteroids)
1 hour) approprriate) days) corticosteroids)

Contraindication to colchicine,
NSAIDs and corticosteroid (oral or
injectable)

Resolution of Educate to self-medicate

Consider IL-1 blocker consider initiation of ULT
flare

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TREATMENT OPTION FOR GOUT

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THANK YOU