GOUT, OSTEOPOROSIS, OSTEOMYELITIS AND

PAGET’S DISEASE

J. Steuart Richards, MD

Assistant Chief, Rheumatology Section

VAMC, Washington, DC

Assistant Professor of Medicine

Georgetown University

Definitions Gout is a syndrome caused by an inflammatory

response to the formation of mono-sodium urate

monohydrate crystals which develop secondary to

hyperuricemia

Hyperuricemia occurs when the serum uric acid level is

> 7.0 mg/dl (420 μmol/L)

Asymptomatic hyperuricemia occurs when serum uric

acid is elevated but there are no signs of gout or renal calculus

Prevalence of Gout

Overall prevalence is 4.6% in men and 2% in women > 451

6%-7% of VA population is estimated to have gout

Incidence of gout estimated at 45.9/100,000 in 1995 -96 vs. 20.2/100,000 in 1977-782

Contributing factors include - ↑ longevity, ↑ HTN,

↑ obesity, ↑ metabolic syndrome, ↑ ESRD, ↑ aspirin, ↑ transplantation use of cyclosporine

1US National Health Survey of 1996 on self reported prevalence2Arromedee et al J Rheumatol 2002;29:2403-06

Evolution of Hyperuricemia and Gout

AsymptomaticHyperuricemia

Acute Flares AdvancedGout

Painless Intercritical Segments

Painful Intercritical

Segments

Pai

n

Time

Over time, untreated, chronic hyperuricemia increases body urate stores, advancing the severity of the disease

Flares last longer

Flares occurmore often

Intercritical segments decrease

Persistent pain and stiffness

Adapted from Klippel et al, eds. In: Primer on the Rheumatic Diseases. 12th ed. Arthritis Foundation; 2001:313.

1

1. Photos courtesy of Brian Mandell, MD, PhD, Cleveland Clinic.2. Photo courtesy of N. Lawrence Edwards, MD, University of Florida.3. ACR Clinical Slide Collection on the Rheumatic Diseases, 1998.

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Diagnosis of Gout

Clinical Presence of

monosodium urate crystals

Presence of tophii Radiographic

features Uric acid

Causes of Disability in Gout

Acuteshort term limitation

of activity Dependent on:

○ Location○ Severity○ Number of joints○ Frequency of

attacks○ Duration of attacks

ChronicChronic limitation of

activityDependent on:

○ Location○ Number of joints○ Severity of joint

damage○ Superimposed flares

Definition

Osteoporosis is a skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture

Bone strength reflects the integration of bone density and bone quality

Bone density is grams of mineral/area or volume measured by DXA

Bone quality encompasses architecture, bone turnover and damage accumulation

NIH Consensus Development Panel. JAMA 2001

Bone Loss with Advancing Age

Secondary Causes of Osteoporosis

Alcohol Cigarette smoking Low BMI Low vitamin D and Calcium intake Immobilization/ sedentary lifestyle Hypogonadism Hyperthyroidism Hypercalciuria Thalassemia/ Hemochromatosis Corticosteroids Anticonvulsants

Clinical

Osteoporosis is asymptomatic unless a fracture occurs

Hip fractures cause loss of mobility, dependence on assistive devices for walking, NH placement and increased mortality

Vertebral fractures result in loss of height, change in posture, pain, sleep disturbance and increased mortality

Osteoporosis in Men

3% - 6% of men > 50 have osteoporosis 28% - 47 % of men > 50 have osteopenia1

Rates were highest for Caucasian and Asian men compared with AA men, Hispanic men were intermediate

Mortality rate following hip fractures is almost double that of women 31% vs. 17%2

1Looker AC et al J Bone Miner Res 11997; 2:1761-17682Forsen L et al Osteoporosis Int 1999;10:73

VA Perspective

Prevalence of Osteoporosis in Men in a VA Rehabilitation Center

Arthur Swislocki, MD; Jon A. Green, MD, PhD; Gerhard Heinrich, MD; Charles A. Barnett, MD; Ivan D. Meadows, MD; Ernest B. Harmon, BS; Mary F. Rank, RN, FNP; and Robert H. Noth, MD

Hip Fractures

1.6 million hip fractures occurs worldwide

28% occur in men Highest incidence in

Caucasians 50% of men require

institutionalization 1 year mortality post hip

fracture for men is 31% vs. 17% for women

Forsen L et al Osteoporosis Int 10:73, 1999

Vertebral Fractures

Increases after the age of 55

Men and women have a similar rate of vertebral fractures

Association with poor sleep, pain, social isolation functional impairment

Increased mortality

Disability and Osteoporotic Fractures

Vertebral Fractures

Pain

Sleep disturbance

Loss of height

Respiratory disease

Depression

Loss of mobility

Hip Fractures

Loss of ambulation

Need for walking aids or wheelchair

Loss of independence, unable to live alone

Chronic pain

Osteomyelitis Definition:

Infection of bone Acute or chronic

Risk Factors: Trauma Diabetes Hemodialysis IV drug abuse Surgery Skin infections

Complications

Sepsis

Septic arthritis

Sinus tracts to skin

Fractures

Chronic osteomyelitis

Avascular necrosis

Disability from Osteomyelitis

Acute

Pain

Limitation of function of affected bone

Restricted movement for treatment with IV antibiotics

Chronic

PainFatigueLoss of function of

affected limbAmputationSocial isolationDepression

Paget’s Disease Definition:

Osteitis Deformans Focal disorder of bone metabolism

leading to accelerated remodeling and bone overgrowth

Involves:○ Pelvis○ Spine○ Skull○ long bone

Paget’s Disease Often asymptomatic

Symptoms depend on the bone involved: Pain Skeletal deformities Osteoarthritis Fractures Tumors Heart Failure Neurological symptoms

Deformity of the affected bone

Disability from Paget’s Disease Osteoarthritis

PainLimitation of movementRequiring assistive devices – cane, walker,

wheelchairSleep disturbance

Heart FailureLimitation of work and exercise capacitySleep disturbance