Gout Arthritis In Young Age

Heri Gunawan, Blondina M., OK. Moehad Sjah

Rheumatology Division
Department of Internal Medicine
Faculty of Medicine University of North Sumatera
H. Adam Malik Hospital
 Introduction
 Gout is a group of diseases that occur due to deposits of
crystals of monosodium urate in the tissues and body
fluids.
 The development of the disease toward chronic gout is
characterized by the accumulation of monosodium urate
crystals (MSU) in joints, cartilage, tendon, bursae, bone,
and soft tissue known as tophi.
 Risk factors: male gender, obesity, hypertension,
excessive alcohol intake, diuretic use, meat and seafood,
and poor kidney function.
 Gout is more common in men. Estimates of gout
prevalence were 5.9% in men and 2% in women.
 The levels of uric acid increase for 10-20 years before the
onset of gout arthritis.
 In men, uric acid levels start to increase at puberty, and
the peak age of gout arthritis onset in men is in the fourth
to sixth decade of life.
 Faster onset may occur in early 20s in men who have a
genetic predisposition and lifestyle risk factors.
 Epidemiology
 The prevalence of this disease among adults is estimated
at 3.9% based on data from the National Health and
Nutrition Examination Survey (NHANES).
 The prevalence of this disease is about 20% in patients
with a family history of the same disease.
 The dominant gout age range: 30-60 years.
 In 1988, dr. John Darmawan: of 4,683 people aged 15-45
years of Bandungan Central Java, it was found that the
prevalence of hyperuricemia was 24.3% in males and
11.7% in women.
 Case Report
A 22 years old man came to the emergency room with severe pain on the left
shoulder joint. This is experienced by the patient since 6 months ago so that
it can’t move as usual. Initially, pain comes suddenly, intermittent and worse
if the joint is moved. In this month, the pain is getting worse. Swollen on the
left shoulder joint found 1 month before admission to hospital. Left shoulder
joint stiffness in the morning (+) about 5 minutes.

Pain on both knee joints (+) for 1 month and getting worse when walking.
The knee joint stiffness (+) 1 this month. The history of the knee joint was
swollen and red (+). History of having an accident involving the knee joint (-).
Pain on the left foot is experienced in this 2 months. Pain is sudden and
recurrent.

Lumps on both the soles of the feet, toes and the inner side right foot (+) 1
year. The lumps are solid, with no tenderness. The history of the lump
ruptured and excreted creamy chalky discharge (+). History of consuming
alcohol (-). The history of family suffers from the same disease (-). History of
peeing out “gravel” or “sand” (-)
Status praesens: Sens: CM, BP: 120/80 mmHg, Pulse: 88 x/menit, RR: 20
x/menit, VAS: 8.
Physical Examination: Superior extremities: swelling (+) o/t regio shoulder
joint sinistra, tophii (+) o/t regio elbow joint dextra et sinistra, manus dextra
et sinistra. Inferior extremities: swelling, kalor, rubor, dolor (+) o/t regio genu
dextra et sinistra, tophii (+) o/t regio digiti I-II pedis dextra et sinistra,
maleolus medialis pedis dextra, plantar pedis dextra et sinistra, efusi (-),
tenderness (-).
Laboratorium:
Hb 12,1 g/dl, Leukocyte 16.980/mm3, Ht 40.1 %, Thrombocyte
421.000/mm3, MCV : 87.70 fL; MCH : 31.10 ρg; MCHC : 34.30 g/dl.

RFT: Ureum : 35.80 mg/dL (N : <50) ; Creatinin : 1.54 mg/dL (N : 0,50-

0,90); Uric Acid: 10,7 (N: <7.0).

Random blood sugar test: 109.00 mg/dL.

Electrolyte: Na 139 mEq/L; K 4,8 mEq/L; Cl 108 mEq/L; Mg 1.72 mEq/L (N :

1.4-2.1); Ca 9.3 mg/dL (N : 8.8-10.2); P 4.3 mEq/L (N : 2.7-4.5).

Rheumatoid factor : Negative.

Urinary Uric Acid (urine 24 jam): 356.32 mg/24jam (N : 200-1000).

Urinalysis: Color: yellow, Clarity/Turbidity: clear, Glucose: (-), Protein: (-),

Reduction reaction: (-), Bilirubin: (-), Urobilinogen: (-), pH: 5, Specific
Gravity: 1,005, Nitrit: (-), Blood: (-), Sediment WBC: 1-2/lpb, RBC: 0-1/lpb,
epitel: 0-1, casts: (-), crystal: (-), yeast: (-).
Radiology:
• Pedis Sinistra AP/Oblique X-rays: Density of bones decreased,
tarsometatarsal pedis bilateral narrowed, marginal erosion in proximal
metatarsal digiti II, focal soft tissue swelling  sugestif Gout Arthritis.
Radiology:
• Left Shoulder Joint X-Rays: focal soft tissue swelling regio axilla
bilateral.
Radiology:
• Genu sinistra AP/Lat X-Rays: Density of the periarticular region bone
especially proximal cruris sinistra seen decreased, marginal erosion on
distal lateral side os femur sinistra (over hanging edge), focal soft tissue
swelling in bilateral genu region suggestive of gout arthritis especially left
genu.
 Kidney and Urinary Tract US: normoscan.

DX: Gout Artritis + Acute Kidney Injury stadium

risk.

Th:/ Inj. Ketorolac 30 mg/8hours, Colchicine tablet

@ 0.5mg 2 tablets initially, then 1 tablet every 2
hours until pain disappears (max dose 8 mg per
day (16 tablets), maintenance dose 2x0.5mg),
Paracetamol 2x1000mg.
DISCUSSION
 LITERATURE
• Natural history of gout arthritis:
asymptomatic hyperuricemia,
acute attack gout arthritis,
intercritical stage, chronic gout
arthritis stage.
• Approximately 60% of Gout
cases are monoarticular, the
rest Poliarticular.
• Symptom of pain is
intermittent.
• There may be swelling of the
involved joints.
• In chronic arthritis gout stage,
can be found tofus and
excreted creamy chalky
discharge.
CASE
• Pain in the left shoulder joint (+)
comes abruptly and intermitten.
• Swelling in the left shoulder joint
(+).
• Pain in both knee joints (+).
• The history of the knee joint was
swollen and red (+).
• Lumps on both soles of the feet,
toes and inner right foot (+).
• The lumps are solid with no
tenderness. The history of the
lump breaks and excreted a
chalk-like discharge (+).
 LITERATURE CASE

• The differential diagnosis

of gout arthritis is • We found lumps on both
pseudogout. soles of the feet, toes
• The gold standard of gout and inner right foot
arthritis: MSU crystals within 1 year in this
(Monosodium Urates) are patient.
found in fluids or tophus. • The lumps are solid with
• The main difference no tenderness.
between gout and • The history of the lump
pseudogout is there is no ruptures and excreted
tophus in pseudogout. chalk-like discharge (+).
 LITERATURE CASE

• Laboratory findings
on Gout Arthritis are
not specific.
In this case, uric acid
• Increased levels of
levels: 10.7 mg / dL
uric acid may be a
(N <7 mg / dL).
clue although 40% of
gout arthritis patients
may have normal uric
acid levels.
 LITERATURE
X-rays findings in Gout Arthritis:
• Punched-out are on joint
surface.
• Bone Erosion
• Joint Destruction
• Subcutaneus Tophi
• Calcification of Tophi
• Asymmetrical Periarticuler
Swelling
• “Overhanging” edges
characterized as appearing like
“rat-bites”
CASE
• Pedis Bilateral AP/Oblique: Density
of bones decreased, tarsometatarsal
pedis bilateral narrowed, marginal
erosion in proximal metatarsal
digiti II, focal soft tissue swelling 
sugestif Gout Arthritis.
• Shoulder Joint Kiri: focal soft tissue
swelling regio axilla bilateral.
• Genu Bilateral AP/Lat: Density of
the periarticular region bone
especially proximal cruris sinistra
seen decreased, marginal erosion on
distal lateral side os femur sinistra
(over hanging edge), focal soft tissue
swelling in bilateral genuine region
suggestive of gout arthritis
especially left genu.
LITERATURE CASE

In this case:
• Asymmetric left shoulder
joint swelling from
radiological examination
• Hyperuricemia
• A history of redness in the
knee joint
• Acute arthritis attacks more
than once
• Tophi
• An acute attack involving
the left joint tarsal.
 LITERATURE CASE

• Management of gout arthritis

in acute attacks includes Therapy in this case:
NSAIDs, colchicine, • Inj. Ketorolac 30 mg/8hours
intraarticular corticosteroid • Colchicine tablet @ 0.5mg 2
injection and interleukin-1 tablets initially, then 1 tablet
inhibitors. every 2 hours until pain
• Colchicine administration in disappears (max dose 8 mg
acute phase: Colchicine @ 0.5 per day (16 tablets))
mg 2 tablets initially, then 1 • Paracetamol 2x1000mg
tablet every 2 hours until it
feels uncomfortable in
abdomen (max dose 8 mg /
day).
 CONCLUSION
• We reported a case of gout arthritis in a 22-year-old
man.
• Diagnosis is based on anamnesis, physical
examination, laboratory and radiology examination.
• Patient’s therapy: Inj. Ketorolac 30 mg/8hrs,
Colchicine tablets @ 0.5mg 2 tablets initially, then
1 tablet every 2 hours until the pain disappears
(max dose 8 mg per day (16 tablets)), Paracetamol
2x1000mg and shows clinical improvement.
Thank You