Gout: Crystal induced arthropathy
Gout is Crystal induced arthropathy caused by monosodium urate crystals. More common in men than women. Associated with hypertension, obesity, diabetes, and old age. Hyperuricemia (>6.8mg/dl) leads to the precipitation of uric acid and the formation of needle-shaped crystals. These crystals in joint space induce inflammation.
Acute gout
The extreme pain of the affected joint. Most commonly great toe is affected, also called Podagra. Chances of uric acid precipitation are higher in extremities where the temperature is low. Sudden onset of pain typically awakes the person in the middle of the night. The painful event is commonly associated with alcohol or smoking. Toe shows all signs and symptoms of acute inflammation (redness, pain, swelling, tenderness and increased temperature).
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Chronic Gout
Stiff and deformed joint with multiple white yellow “Tophi” or subcutaneous nodules. Tophi consist of multinucleated giant cells, needle-shaped crystals, and inflammatory mediators. Repeated attacks of acute gout damages bones and cartilage of joints.
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Interesting facts
Early signs of chronic lead intoxication are attributable to proximal tubule dysfunction, particularly hyperuricemia as a result of reduced urate secretion. The triad of “saturnine gout,” hypertension, and renal insufficiency should prompt a physician to ask specifically about lead exposure.
Cases with a large turnover of hematopoietic cells, for example, polycythemia vera causes hyperuricemia with secondary gout and uric acid stones in the kidney.
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Risk factors for Hyperuricemia
Disorder of reduced excretion (more common than overproduction)
- Chronic renal insufficiency
- Medicines- Thiazides, Cyclosporine, loop diuretic, low dose aspirin, and allopurinol.
- Ketoacidosis- Starvation, lactic acidosis or diabetes
Disorder of overproduction
- Increased cell turnover – tumor lysis syndrome, ineffective erythropoiesis, leukemias, and chemotherapy.
- Genetic illness with enzyme deficiency – Lesch-Nyhan syndrome, Von Gierke disease
Diagnosis
Synovial fluid aspiration and crystal analysis – Needle-shaped birefringent crystals under polarized light are the gold standards for diagnosis.
Serum Uric acid levels- more than 6.8 mg/dl is diagnostic. Uric acid levels can be normal and low at the time of attacks.
Treatment
Acute attack – it is an acute inflammatory reaction and anti-inflammatory drugs are most suitable. uricosuric or urate reducing drugs aren’t given, especially Allopurinol and aspirin, they both worsen the symptoms.
NSAIDS – Indomethacin, Ibuprofen
Corticosteroid- Oral prednisone
Colchicine
Chronic Gout- the main aim is to keep uric acid low, reduce crystal formation, and have acute attack frequency.
Xanthine Oxidase Inhibitors – Allopurinol
Uricosuric drugs – probenecid
Recombinant Uricase- RasbUricase
Lifestyle modification
Purine restricted diet (low protein diet).
Diabetes and hypertension should be controlled.
Alcohol and smoking cessation.
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