Gout
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Introduction
Gout is an arthritis caused by urate crystal collection. Abnormal purine metabolism leads to hyperuricemia, with crystals of monosodium urate thereby being deposited in tissues or synovium.
Gout affects men ages 35-50 and women after menopause.
The Case of...
a simple case introducing clincial presentation and calling for a differential diagnosis to get students thinking.
Causes and Risk Factors
Primary gout is genetic, with the majority of cases due to decreased renal excretion of urate. A minority of cases are due to overproduction or altered enzyme function.
Secondary gout has a number of causes:
- increased intake (meat, seafood)
- increased production (high nucleic acid turnover conditions)
- decreased excretion (renal failure, medications, medical conditions)
Most people with increased urate levels do not have gout.
Risk factors include:
- family history
- alcohol
- renal disease
- medications (eg dieuretics)
- hypertension
- elevated cholesterol
- insulin resistance
- hypothyroidism
- hyperparathyroidism
- obesity
Precipitating factors
- excessive alcohol intake
- recent surgery
- recent illness
- trauma
- starting or stopping allopurinol
- travel
- dehydration
Pathophysiology
Tophi are precipitated deposits of uric acid. They are often found in the fingers, toes, elbows, ears, or heels.
Signs and Symptoms
- history
- physical exam
History
Physical Exam
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Diagnostic Imaging
Differential Diagnosis
Treatments
Acute attacks
Acute treatment:
- NSAID x2-3 days; opioids and splinting until effect (avoid with renal disease)
- colchicine (titrate to diarrhea; highly lethal toxicity)
- prednisone
- intra-articular injection of corticosteroid
- steroid injection
Do NOT start allopurinol acutely; this can worsen the attack, and should be started only afterwards, with specific criteria:
- uric acid lower than normal range
Consequences and Course
Resources and References
Rheuminfo.com
Topic Development
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