KUSHAGRA , MS IV, MAMC, DELHIDR. GILLIAN LIEBERMAN, M.D.
AUGUST 23, 2010
DefinitionEpidemiology Pathophysiology, Etiology and Risk Factors Stages and Clinical FeaturesAssociated Co-MorbiditiesCommon Sites and Distribution Patient DiscussionClassical Findings Differential DiagnosisMenu of Imaging StudiesManagement and Preventive Measures
Kushagra, MAMC MS IV Gillian Lieberman, MD
GOUT is a form of peripheral arthritis resulting from the deposition of monosodium urate crystals secondary to hyperuricemia.
The metatarsal- phalangeal joint at the base of the big toe is the mostcommon affected.( Alsoknown as PODAGRA).
Kushagra, MAMC MS IV Gillian Lieberman, MD
emedicine.medscape.com
Gout is a common systemic metabolic disease, affecting more than 1% of the population.
It is the most common inflammatory arthritis, afflicting 1 or more joints in men older than 40 years of age.
Typically occurs in middle aged or elderly males (90% of cases are in males).
Prevalence in the United States: 1.6 to 13.6 per 1000.
Kushagra, MAMC MS IV Gillian Lieberman, MD
Gout can be broadly classified into 2 types:PRIMARY
SECONDARY
Gout is called Primary when no identifiable disease causing the hyperuricemia can be found.
Primary Gout occurs in Majority of the cases.
Secondary Gout, which is less common, occurs due to some underlying disease.
Kushagra, MAMC MS IV Gillian Lieberman, MD
Causes can be broadly classified into :
INCREASED URIC ACID PRODUCTION (5%-10% of patients)
DECREASED URIC ACID EXCRETION (90%-100% of patients)
Kushagra, MAMC MS IV Gillian Lieberman, MD
INCREASED URIC ACID PRODUCTION (5%-10% of patients)
Genetic enzymatic defects
Hypoxanthine-guanine phosphoribosyl transferase deficiency
glucose-6-phosphatase deficiency
5-phosphoribosyl-1-pyrophosphate synthetase overactivity
Kushagra, MAMC MS IV Gillian Lieberman, MD
INCREASED URIC ACID PRODUCTION (5%-10% of patients)
Acquired causes
Dietary indiscretions: excessive purine diet
Obesity
Increased tissue turnover—tumors, lympho-proliferative disorders
Vigorous muscle exertion causing increased turnover of ATP
Alcohol-induced turnover of ATP
Chemotherapy
Kushagra, MAMC MS IV Gillian Lieberman, MD
DECREASED URIC ACID EXCRETION (90%- 100% of patients)
Genetic causes
Down syndrome
Polycystic kidney diseases
Acquired causes
Diminished renal function
Inhibition of tubular urate secretion:competitive anions (keto-acidosisand lactic acidosis)
Kushagra, MAMC MS IV Gillian Lieberman, MD
DECREASED URIC ACID EXCRETION (90%- 100% of patients)
Acquired causes
Enhanced tubular urate reabsorption:
Dehydration
Starvation
Insulin resistance (metabolic syndrome)
Medications:
Low-dose aspirin
Thiazide and diuretics
Ethambutol
Niacin
Lead nephropathy
Kushagra, MAMC MS IV Gillian Lieberman, MD
Humans do not express the enzyme urate oxidase (uricase), because of a mutation during evolution of the uricase gene, which converts urate to the more soluble and easily excreted compound allantoin.
Less Soluble More Soluble
Kushagra, MAMC MS IV Gillian Lieberman, MD
Among mammals, only humans and other primate species excrete uric acid as the end product of purine metabolism.
Uric acid is a weak organic acid that exists mainly as the urate ion at pH >5.75 and as the un-ionized uric acid form at more acidic (lower) pH levels.
Thus, the urate form predominates in allextracellular fluids, including serum, in which physiological pH is 7.4. In urine, which is usually acidic, the un-ionized uric acid form predominates.
Kushagra, MAMC MS IV Gillian Lieberman, MD
When overproduction or underexcretion of uric
acid occurs, the serum urate (SU)
concentration may exceed the solubility of
urate (a concentration approximately >6.8mg/dl),
and supersaturation of urate in the serum (and
other extracellular spaces results. This state, called
hyperuricemia, imparts a risk of crystal deposition
of urate in tissues from the supersaturated fluids.
Kushagra, MAMC MS IV Gillian Lieberman, MD
1. ASYMPTOMATIC STAGE
2. ACUTE GOUTY ARTHRITIS
3. INTER-CRITICAL GOUT
4. CHRONIC TOPHACEOUS GOUT
Kushagra, MAMC MS IV Gillian Lieberman, MD
ACUTE GOUTY ARTHRITIS
90% of attacks involve a single joint with severe pain, redness and swelling.
Mostly involving the lower extremity, usually the first metatarsal-phalangeal joint.(>50%)
Kushagra, MAMC MS IV Gillian Lieberman, MD
beliefnet.com qwickstep.com
INTER-CRITICAL GOUT
These are asymptomatic intervals between acute attacks most common early in disease progression.
This pattern is quite uncommon in other arthritic disorders and alone is very suggestive of gout.
Kushagra, MAMC MS IV Gillian Lieberman, MD
CHRONIC TOPHACEOUS GOUT
The tophus is the pathognomonic lesion of gout and is essentially a foreign body granuloma.
Seen in the external ear and pressure points over the elbows, hands, feet, knees, and forearms.
Kushagra, MAMC MS IV Gillian Lieberman, MD
cedar-sinai.eduhopkins-arthritis.org
PAIN
Rapid onset and progression.
Worst pain that the person has ever endured.
Associated with warmth, redness, and swelling of the affected joint.
Systemic symptoms and signs of fatigue, fever and chills may accompany.
The first episode of gouty arthritis often begins at night.
Kushagra, MAMC MS IV Gillian Lieberman, MD
GOUTY NEPHROPATHY
Two renal syndromes are associated with hyperuricemia:
acute urate nephropathy and
uric acid urolithiasis..
Uric acid stone Calcium oxalate stones
Kushagra, MAMC MS IV Gillian Lieberman, MD
kidney-stone-treatment.blogspot.com lithostat.com
Patients also have an increased incidence of calcium oxalate stones because urate crystals serve as nidus for calcium stone formation.
Isosthenuria (inability to concentrateurine), pyelonephritis and proteinuria are other renal manifestations.
Kushagra, MAMC MS IV Gillian Lieberman, MD
BONE EROSIONS
Deposits of urate crystals (tophi) form along the margins of the articular cortex and may erode the underlying bone, producing small, sharply marginated, punched-out defects at the joint margins of the small bones of the hand and foot.
Frontal and Lateral view of the Index finger showing pressure erosion Large soft tissue mass associated
On the volar surface of middle phalanx by soft tissue mass. With osteolysis of first MTP joint.
Kushagra, MAMC MS IV Gillian Lieberman, MD
appliedradiology.com
SOFT TISSUE ABNORMALITIES
Tophi (Soft Lumpy Nodule) can be seen radiologically most commonly at:
First metatarsophalangeal joint
The ear
Olecranon bursa and
The Achilles tendon
Ear Tophi Tophi on Knee
Kushagra, MAMC MS IV Gillian Lieberman, MD
wikipedia.org wikipedia.org
BONE MINERALISATION
The bone mineral density is preserved until late in the disease.
Extensive osteoporosis is not a feature ofgout.
The presence of normal mineralization may help differentiate this condition from rheumatoid arthritis.
The reason for the presence of normal mineralization is that the duration of the attack is too short to allow the development of osteoporosis of disuse as is seen in rheumatoid arthritis.
Kushagra, MAMC MS IV Gillian Lieberman, MD
CHONDROCALCINOSIS
Five percent of patients with gout have cartilage calcification or chondrocalcinosis.
Chondrocalcinosis manifests because they have a predisposition for calcium pyrophosphate dihydrate crystal deposition disease (CPPD).
ARTICULAR ABNOMALITIES
The joint space is well preserved until late in the course of the disease.
The presence of relatively normal joint space and preservation of the articular cartilage with extensive erosions is a distinctive radiographic feature of gout.
BURSITIS
Kushagra, MAMC MS IV Gillian Lieberman, MD
CARDIOVASCULAR DISEASES:
HYPERTENSION
MYOCARDIAL INFARCTION
STROKE
METABOLIC SYNDROME
OBESITY
HYPERTENSION
HYPERLIPIDEMIA
INSULIN RESISTANCE
Kushagra, MAMC MS IV Gillian Lieberman, MD
Kushagra, MAMC MS IV Gillian Lieberman, MD
sedico.net
Lower extremity > upper extremity
Small joints > large joints
Random distribution in hands (helpful diagnostic distinction)
First MTP most common (podagra)
Asymmetric distribution is characteristic of gouty arthritis.
Kushagra, MAMC MS IV Gillian Lieberman, MD
Joint Freque ncy
DIP ++
1st IP ++
2nd-5th PIP ++
1st MCP ++
2nd-5th MCP ++
1st CMC +++
2-5 CMC +++
Midcarpal +++
Radiocarpal ++
Radioulnar ++
Kushagra, MAMC MS IV Gillian Lieberman, MD
gentili.net
81 year old lady came to the OPD with soft lumpy nodules over hands.
She was having difficulty in extending fingers of the Right hand.
She had episodes of pain, redness and swelling in the Right hand since past 10 years. The left hand got involved over a period of time.
Denies any recent fever, fatigue or weight loss
She is having nodules at the right elbow and 1st MTP in both feet.
Kushagra, MAMC MS IV Gillian Lieberman, MD
Extensively calcified tophi and bony destructive changes are seen involving the DIP and PIP joints of the 2nd, 3rd and 4th digits.
Erosions are seen at the base of the 1st metacarpal, head of the 2nd metacarpal and ulnar styloid process.
Kushagra, MAMC MS IV Gillian Lieberman, MD
PACS BIDMC
Patient is unable to extend the fingers of her Right hand.
Erosions are noted in the right hand at the head of the 5th metacarpal and base of the 1st metacarpal bones.
Kushagra, MAMC MS IV Gillian Lieberman, MD
PACS BIDMC
Bony destruction with overhanging cortical edges are noted along the lateral condyle.
Adjacent subchondral cysts and osseousfragments are noted within this region.
Kushagra, MAMC MS IV Gillian Lieberman, MD
PACS
Extensive destructive changes of all digits involving the MTP, PIP and DIP joints of the right feet are noted with extensively calcified large tophi.
Kushagra, MAMC MS IV Gillian Lieberman, MD
PACS BIDMC
Tarsometatarsal and ankle joint tophi and bony destruction can be seen.
Marked bony destruction can be noted on MTP, DIP and PIP.
Kushagra, MAMC MS IV Gillian Lieberman, MD
PACS BIDMC
Extensive destructive changes of all digits involving the MTP, PIP and DIP joints of the left feet are noted with extensively calcified large tophi.
There are medial subluxations of the 2nd and 3rd metatarsal phalangeal joints of the left foot.
Kushagra, MAMC MS IV Gillian Lieberman, MD
PACS BIDMC
Tarsometatarsal and ankle joint tophi and bony destruction can be seen.
Marked bony destruction can be noted on MTP, DIP and PIP.
Kushagra, MAMC MS IV Gillian Lieberman, MD
PACS BIDMC
Lateral radiograph of the elbow
Amorphous calcified tophaceous deposits in the olecranon bursa.
Kushagra, MAMC MS IV Gillian Lieberman, MD
appliedradiology.com
Gout- Olecranon Bursitis.
There is soft tissue swelling in the olecranon bursa (white arrow) a finding suggestive of gout.
There are also erosions (blue arrows) around the elbow joint.
There is no periarticular demineralization.
Kushagra, MAMC MS IV Gillian Lieberman, MD
learningradiology.com
Frontal view of the index finger
Well-defined subarticular cyst in this patient who has gouty arthritis.
Kushagra, MAMC MS IV Gillian Lieberman, MD
appliedradiology.com
Frontal Radiograph of the foot
Erosion with Typical overhanging edge at the head of the first metatarsal.
Kushagra, MAMC MS IV Gillian Lieberman, MD
appliedradiology.com
Lateral radiograph of the ankle
Thickened Achilles tendon due to deposition of urate crystals.
The integrity of the Achilles tendon is apparently maintained.
Kushagra, MAMC MS IV Gillian Lieberman, MD
appliedradiology.com
CPPD (Pseudo gout)
Psoriasis
Rheumatoid arthritis
Amyloidosis
Joint infection
Osteoarthritis
Xanthomatosis
Kushagra, MAMC MS IV Gillian Lieberman, MD
GOUT PSEUDOGOUT
Ratio of men to women 7:1 1:1.5
Age group affected Men >40 years oldPostmenopausal women
Elderly
Serum urate Elevated Normal
Joints involved First MTP joint, knees, wrists, fingers, olecranon bursa
Knees, wrists, ankles
Involvement of 1st MTP Common Rare
Tophi Present Rare tophi-likedeposits
Radiographic findings
Erosions with overhanging edges
Chondrocalcinosis
Crystals Needle-shaped, strong negative birefringence
Rhomboid-shaped,weakly positivebirefringence
Kushagra, MAMC MS IV Gillian Lieberman, MD
PSORIASIS
progressive joint-space destruction
paravertebral ossification
sacroiliac joint involvement
RHEUMATOID ARTHRITIS
presence of symmetric distribution
early joint-space narrowing
osteopenia.
Kushagra, MAMC MS IV Gillian Lieberman, MD
JOINT INFECTION
rapid destruction of joint space
loss of the lamina dura (articular cortex) over a continuous segment of the bone.
AMYLOIDOSIS
Bilateral and symmetric
Periarticular osteopenia is frequent.
Kushagra, MAMC MS IV Gillian Lieberman, MD
XANTHOMATOSIS
foci of soft-tissue deposition of cholesterol and lipid products.
Laboratory work-up for differentiation
OSTEOARTHRITIS
elderly women
symmetric distribution
Erosion of the joint space
Kushagra, MAMC MS IV Gillian Lieberman, MD
X-RAY FILM
COMPUTED TOMOGRAPHY (CT) SCANS
MAGNETIC RESONANCE IMAGING (MRI)
ULTRA SOUND
Kushagra, MAMC MS IV Gillian Lieberman, MD
normal mineralization
joint space preservation
sharply marginated erosions with sclerotic borders
overhanging edges
asymmetric polyarticular distribution
LIMITATIONS
Indicates the chronicity 6-8 years after the initial attack
Kushagra, MAMC MS IV Gillian Lieberman, MD
reveal MSU deposits in vitro as well as within the knee joint
readily diagnose stones of the urinary tract not visible on conventional radiographs
Kushagra, MAMC MS IV Gillian Lieberman, MD
detects early subclinical tophaceous deposits
determining the extent of disease in tophaceous gout
provides information regarding the patternsof deposition and spread of MSU crystals.
Kushagra, MAMC MS IV Gillian Lieberman, MD
more reliable, noninvasive method for diagnosis
can detect deposition of MSU crystals on cartilaginous surfaces, as well as tophaceous material and typical erosions
Kushagra, MAMC MS IV Gillian Lieberman, MD
ASYMPTOMATIC HYPERURICEMIA
Usually requires No treatment except in:
Elevated Serum Uric acid level
Positive Family history of tophaceous gout
Treated with Allopurinol under closed medical observation
Kushagra, MAMC MS IV Gillian Lieberman, MD
ACUTE GOUTY ARTHRITIS
Joint immobilization
Colchicines
Nonsteroidal anti-inflammatory agents(NSAIDs)
Corticosteroids
Uricosuric agents and allopurinol are of no value in treatment of the acute attack.
Kushagra, MAMC MS IV Gillian Lieberman, MD
INTER-CRITICAL GOUT (INTERVAL PERIOD)PREVENTIVE MEASURES
Kushagra, MAMC MS IV Gillian Lieberman, MD
CHRONIC GOUTY ARTHRITIS
Allopurinol is the drug of choice
Uricosuric drugs, such as Probenecid and Sulfinpyrazone, may also be used
In selected patients, large deforming tophi may be excised surgically
Kushagra, MAMC MS IV Gillian Lieberman, MD
DR. GILLIAN LIEBERMAN
GRAHAM FRANKEL
DR. VERONICA FERNANDES
DIKSHITA DUBEY
SNEHANSH ROY CHAUDHARY
TEJESHWAR SINGH JUGPAL
Kushagra, MAMC MS IV Gillian Lieberman, MD
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Kushagra, MAMC MS IV Gillian Lieberman, MD