Crystalopathies Joanna Zalewska

Gout Inflammatory arthritis with crystallization of monosodium urate crystals in joint or soft tissue

Classification Asymptomatic hyperuricaemia Acute gout Recurrent attacks Chronic tophaceous gout Urolithasis

Risk factors Overall body weight or central obesity Very rapid weight loss through dieting Hypertension Loop and thiazide diuretics Alcohol

Key features in history- acute First attacks are usually monoarticular with the metatarsophalangeal joint of the great toe Other joints- wrist, elbow, small joints of hand Attacks self-limiting after 5-7b days Onset is often lateat night or in the early morning Before- surgery, dehydratation, alcohol intake

Key features in history- chronic Polyarticular Repeated attacks get closer together and become more prolonged Repeated attacks may result in deformity, reduced rangeof joint movement or chronic pain Tophi

Examination - acute - chronic A hot, swollen, tender joint Involvement of soft tissues - chronic Deformation of joints Tophi- subcutaneously, in bones and organs- painless (white, creamy discharge)

Tests Leucocytosis- acute goat Elevation of ESR and CRP Serum creatinine Serum urate Blood cultures Synovial fluid- crystals of monosodium urate Radiographs- unhelpful in early gout, in late- calcification and erosions (head of the first metatarsal) Ultrasound- synovitis

Treatment Asymptomatic hyperuricaemia does not require treatment Septic arthritis should be considered Terminate the attack as soo as possible Ice therapy, NSAIDs, colchicine, glucocorticosteroids

NSAIDs Colchicine Indometacin- the traditional NSAIDs Naproxen in Poland NSAIDs should be avoided in patients with heart failure, renal insufficiency, history of previous peptic disease Colchicine Most patient respond within 18 h Dose 500 ug 2-4 times daily (diarrhoea)

Glucocorticosteroids Useful in patients who cannot tolerate or not improving with NSAIDs or colchicine Intra-articular injections are effective in monoarthritis or oligoarthritis Oral, intramuscular or intarvenous Prednisolone 20- 50 mg daily for 2 weeks

Inhibitors of the enzyme xanthine oxidase- long term treatment Allopurinol should not be commenced during an acute attack, but should be introduced 1-2 weeks later Low dose of colchicine (500 ug) for 6 months following introduction of allopurinol to avoid attacks The dose should be increased by 50- 100 mg in response to changes in serum urate levels Side effects- rash, allergic reaction, fever, mucositis, dermatitis Febuxostat

Follow-up Lifestyle- diet (avoid food with very high purine content as shellfish, sardines, meat, avoid alcohol, drink 2 l of fluid) Control BP, serum urate, renal function, glucose

Calcium pyrophosphate dihydrate disease (CPDD) Chondrocalcinosis/ pseudogout Deposition of calcium pyrosphoshate dihydrate crystals Diagnostic- polarized light microscopy- gold standard Women age 70

Tests Leucocytosis- acute attacks CRP, ESR elevation Creatinine joint aspiration- rhomboid-shaped crystals under polarized light- the most important Radiology- medial and lateral menisci of the knee, triangular cartilage of wrist, symphis pubis

Treatment NSAIDs Intraarticular injection of glucocorticosteroids Rest the joint Low dose of colchicine (1 mg/ day) Low dose of prednisolone DMARD Joint replacement surgery