Gout and pseudogout: Difference between revisions
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==Clinical Features== | ==Clinical Features== | ||
[[File:Gout2018.jpg|thumb|Acute gout affecting the first MP joint (podagra)]] | |||
[[File:PMC3117776 1757-1146-4-13-2.png|thumb|Tophaceous gout affecting the right great toe and finger interphalangeal joints. Note the asymmetrical swelling and yellow-white discoloration]] | |||
[[File:PMC3117776 1757-1146-4-13-1.png|thumb|Distribution of joints typically affected by gout]] | |||
*Joint pain may develop over period of hours | *Joint pain may develop over period of hours | ||
*Primarily involves first MTP, knee, ankle | *Primarily involves first MTP, knee, ankle | ||
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==Evaluation== | ==Evaluation== | ||
*Synovial fluid aspiration | *Synovial fluid aspiration | ||
**Gout: yellow monosodium urate | **Gout: yellow monosodium urate; negatively birefringent; needle-shaped | ||
**Pseudogout: calcium pyrophosphate | **Pseudogout: calcium pyrophosphate; positively birefringent; rhomboid-shaped | ||
*Serum uric acid levels are not helpful (30% of patients with gout attack have normal levels) | *Serum uric acid levels are not helpful (30% of patients with gout attack have normal levels) | ||
**Uric acid during attacks | **Uric acid during attacks can be low due to the precipitation of gout crystals | ||
** High uric acid is | **High uric acid is >6.8 | ||
*ESR may be elevated | *ESR may be elevated | ||
*'''no bacteria on [[Gram Stain]]''' | *'''no bacteria on [[Gram Stain]]''' | ||
*XR of joint space may have radiolucent calcium pyrophosphate formation | *Pseudogout: XR of joint space may have radiolucent calcium pyrophosphate formation | ||
{{Arthrocentesis diagnostic chart}} | {{Arthrocentesis diagnostic chart}} | ||
==Management== | ==Management== | ||
''Patients usually only require [[opioid]] and [[NSAID]] treatment in the ED with continued [[NSAID]] treatment as an oupatient. However any combination of the following treatments are acceptable<ref>Khanna D. et al. 2012 American College of Rheumatology guidelines for management of gout. Part 2: Therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res. Oct 2012;64(10):1447-61</ref>'' | ''Patients usually only require [[opioid]] and [[NSAID]] treatment in the ED with continued [[NSAID]] treatment as an oupatient. However any combination of the following treatments are acceptable<ref>Khanna D. et al. 2012 American College of Rheumatology guidelines for management of gout. Part 2: Therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res. Oct 2012;64(10):1447-61</ref>'' | ||
===All patients=== | |||
*Hold [[diuretics]] | |||
*Consider starting [[losartan]] to replace diuretic (has modest uricosuric effect) | |||
*Alcohol and dietary counseling | |||
*Continue uric acid-lowering agents if already on prophylactic regimen (do not start) | |||
*Follow up with Primary Doctor or Rheumatology if having continued flares | |||
===[[NSAIDs]]=== | ===[[NSAIDs]]=== | ||
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*Even if gout has been diagnosed in the past, be cautious with glucocorticoid joint injection if the current clinical picture is uncertain since a [[Septic Arthritis|septic joint]] can coexist with gout and a steroid injection would then worsen the patient's clinical status. | *Even if gout has been diagnosed in the past, be cautious with glucocorticoid joint injection if the current clinical picture is uncertain since a [[Septic Arthritis|septic joint]] can coexist with gout and a steroid injection would then worsen the patient's clinical status. | ||
=== | ==Disposition== | ||
*Generally outpatient treatment | |||
* | |||
==See Also== | ==See Also== |
Revision as of 23:21, 10 March 2020
Pathophysiology
- Primarily an illness of middle-aged males and elderly adults
- Gout in females usually occurs only after menopause
- Gout is most common form of inflammatory joint disease in men >40yr
- Presence of crystals does not exclude septic arthritis
Precipitants
- Trauma
- Surgery
- Medication (allopurinol, thiazide/loop diuretics, ASA)
- Alcohol consumption
- Meat/Seafood consumption
- Dehydration
- Lower body temperature
Clinical Features
- Joint pain may develop over period of hours
- Primarily involves first MTP, knee, ankle
Differential Diagnosis
Monoarticular arthritis
- Acute osteoarthritis
- Avascular necrosis
- Crystal-induced (Gout, Pseudogout)
- Gonococcal arthritis, arthritis-dermatitis syndrome
- Nongonococcal septic arthritis
- Lyme disease
- Malignancy (metastases, osteochondroma, osteoid osteoma)
- Reactive poststreptococcal arthritis
- Trauma-induced arthritis
- Fracture
- Ligamentous injury
- Overuse
- Avascular necrosis
- Decompression sickness
- Spontaneous osteonecrosis
- Hemorrhagic (e.g. hemophilia, systemic anticoagulation
- Seronegative spondyloarthropathies (ankylosing spondylitis, IBD, psoriatic arthritis, reactive arthritis
- RA, SLE
- Sarcoidosis, amyloidosis
- Periarticular pathology
- Transient (Toxic) Synovitis (Hip)
- Slipped Capital Femoral Epiphysis (SCFE)
- Legg Calve Perthes Disease
Evaluation
- Synovial fluid aspiration
- Gout: yellow monosodium urate; negatively birefringent; needle-shaped
- Pseudogout: calcium pyrophosphate; positively birefringent; rhomboid-shaped
- Serum uric acid levels are not helpful (30% of patients with gout attack have normal levels)
- Uric acid during attacks can be low due to the precipitation of gout crystals
- High uric acid is >6.8
- ESR may be elevated
- no bacteria on Gram Stain
- Pseudogout: XR of joint space may have radiolucent calcium pyrophosphate formation
Arthrocentesis of synoval fluid
Synovium | Normal | Noninflammatory | Inflammatory | Septic |
Clarity | Transparent | Transparent | Cloudy | Cloudy |
Color | Clear | Yellow | Yellow | Yellow |
WBC | <200 | <200-2000 | 200-50,000 |
>1,100 (prosthetic joint) >25,000; LR=2.9 >50,000; LR=7.7 >100,000; LR=28 |
PMN | <25% | <25% | >50% |
>64% (prosthetic joint) >90% |
Culture | Neg | Neg | Neg | >50% positive |
Lactate | <5.6 mmol/L | <5.6 mmol/L | <5.6 mmol/L | >5.6 mmol/L |
LDH | <250 | <250 | <250 | >250 |
Crystals | None | None | Multiple or none | None |
- Viscosity of synovial fluid may actually be decreased in inflammatory or infectious etiologies, as hyaluronic acid concentrations decrease
- The presence of crystals does not rule out septic arthritis; however, the diagnosis is highly unlikely with synovial WBC < 50,000[1]
Management
Patients usually only require opioid and NSAID treatment in the ED with continued NSAID treatment as an oupatient. However any combination of the following treatments are acceptable[2]
All patients
- Hold diuretics
- Consider starting losartan to replace diuretic (has modest uricosuric effect)
- Alcohol and dietary counseling
- Continue uric acid-lowering agents if already on prophylactic regimen (do not start)
- Follow up with Primary Doctor or Rheumatology if having continued flares
NSAIDs
- Do not give to patients with renal insufficiency (use opioids instead)
- Substantial pain relief should occur within 2hr
- Options:
- Indomethacin 50mg po TID x3-5d, OR
- Naproxen 500mg po BID x3-7d, OR
- Ibuprofen 800mg PO TID x 3-5d
Other options
Colchicine
- Can be used as alternative agent to NSAIDs in patient with normal renal/hepatic function
- 1.2mg PO (load), followed by 0.6mg one hour later x 1 [3]
- May use to maximum of x3 doses, with more aggressive regimens totaling max dose up to 6mg[4]
- Wait at least x3 days before starting another round of colchicine therapy
- Renal impairment not absolute contraindication for acute flare but may consider dose reduction.
- Dose adjustments for CYP3A4 inhibitors (HARRT, Calcium Channel Blockers, fluconazole, erythromycin, clarithromycin)
- Colchicine should not be administered intravenously
Initial: 0.6-1.2mg, followed by 0.6 every 1-2 hours; some clinicians recommend a maximum of 3 doses; more aggressive approaches have recommended a maximum dose of up to 6mg. Wait at least 3 days before initiating another course of therapy
Steroids
- Prednisone 30 to 50mg initially, and gradually tapered over 10 days, results in clinical resolution without rebound pain or complications[5][6]
Glucocorticoid injection
- Even if gout has been diagnosed in the past, be cautious with glucocorticoid joint injection if the current clinical picture is uncertain since a septic joint can coexist with gout and a steroid injection would then worsen the patient's clinical status.
Disposition
- Generally outpatient treatment
See Also
References
- ↑ Shah K, Spear J, Nathanson LA, Mccauley J, Edlow JA. Does the presence of crystal arthritis rule out septic arthritis?. J Emerg Med. 2007;32(1):23-6.
- ↑ Khanna D. et al. 2012 American College of Rheumatology guidelines for management of gout. Part 2: Therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res. Oct 2012;64(10):1447-61
- ↑ Terkeltaub RA et al. High versus low dosing of oral colchicine for early acute gout flare: Twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study. Arthritis Rheum. 2010;62(4):1060.
- ↑ GlobalRPH. http://www.globalrph.com/gout.htm*colchicine
- ↑ Groff GD et al. Systemic steroid therapy for acute gout: a clinical trial and review of the literature. Semin Arthritis Rheum. 1990;19(6):329
- ↑ Janssens H. et al. Use of oral prednisolone or naproxen for the treatment of gout arthritis: a double-blind, randomised equivalence trial. Lancet. 2008;371(9627):1854.