KUSHAGRA , MS IV, MAMC, DELHI DR. GILLIAN ...eradiology.bidmc.harvard.edu/LearningLab/musculo/gupta.pdfKushagra, MAMC MS IV Gillian Lieberman, MD CARDIOVASCULAR DISEASES: HYPERTENSION

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).


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.


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.


Causes can be broadly classified into :

INCREASED URIC ACID PRODUCTION (5%-10% of patients)

DECREASED URIC ACID EXCRETION (90%-100% of patients)



Genetic enzymatic defects

Hypoxanthine-guanine phosphoribosyl transferase deficiency

glucose-6-phosphatase deficiency

5-phosphoribosyl-1-pyrophosphate synthetase overactivity



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


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)


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


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


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.


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.


1. ASYMPTOMATIC STAGE

2. ACUTE GOUTY ARTHRITIS

3. INTER-CRITICAL GOUT

4. CHRONIC TOPHACEOUS GOUT


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%)


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.


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.


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.


GOUTY NEPHROPATHY

Two renal syndromes are associated with hyperuricemia:

acute urate nephropathy and

uric acid urolithiasis..

Uric acid stone Calcium oxalate stones


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.


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.


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


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.


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


CARDIOVASCULAR DISEASES:

HYPERTENSION

MYOCARDIAL INFARCTION

STROKE

METABOLIC SYNDROME

OBESITY

HYPERTENSION

HYPERLIPIDEMIA

INSULIN RESISTANCE



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.


Joint Freque ncy

DIP ++

1st IP ++

2nd-5th PIP ++

1st MCP ++

2nd-5th MCP ++

1st CMC +++

2-5 CMC +++

Midcarpal +++

Radiocarpal ++

Radioulnar ++


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.


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.


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.


PACS BIDMC

Bony destruction with overhanging cortical edges are noted along the lateral condyle.

Adjacent subchondral cysts and osseousfragments are noted within this region.


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.


PACS BIDMC

Tarsometatarsal and ankle joint tophi and bony destruction can be seen.

Marked bony destruction can be noted on MTP, DIP and PIP.


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.


PACS BIDMC

Tarsometatarsal and ankle joint tophi and bony destruction can be seen.

Marked bony destruction can be noted on MTP, DIP and PIP.


PACS BIDMC

Lateral radiograph of the elbow

Amorphous calcified tophaceous deposits in the olecranon bursa.



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.


learningradiology.com

Frontal view of the index finger

Well-defined subarticular cyst in this patient who has gouty arthritis.



Frontal Radiograph of the foot

Erosion with Typical overhanging edge at the head of the first metatarsal.



Lateral radiograph of the ankle

Thickened Achilles tendon due to deposition of urate crystals.

The integrity of the Achilles tendon is apparently maintained.



CPPD (Pseudo gout)

Psoriasis

Rheumatoid arthritis

Amyloidosis

Joint infection

Osteoarthritis

Xanthomatosis


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


PSORIASIS

progressive joint-space destruction

paravertebral ossification

sacroiliac joint involvement

RHEUMATOID ARTHRITIS

presence of symmetric distribution

early joint-space narrowing

osteopenia.


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.


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


X-RAY FILM

COMPUTED TOMOGRAPHY (CT) SCANS

MAGNETIC RESONANCE IMAGING (MRI)

ULTRA SOUND


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


reveal MSU deposits in vitro as well as within the knee joint

readily diagnose stones of the urinary tract not visible on conventional radiographs


detects early subclinical tophaceous deposits

determining the extent of disease in tophaceous gout

provides information regarding the patternsof deposition and spread of MSU crystals.


more reliable, noninvasive method for diagnosis

can detect deposition of MSU crystals on cartilaginous surfaces, as well as tophaceous material and typical erosions


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


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.


INTER-CRITICAL GOUT (INTERVAL PERIOD)PREVENTIVE MEASURES


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


DR. GILLIAN LIEBERMAN

GRAHAM FRANKEL

DR. VERONICA FERNANDES

DIKSHITA DUBEY

SNEHANSH ROY CHAUDHARY

TEJESHWAR SINGH JUGPAL


Brant WE, Helms CA. Fundamentals of Diagnostic Radiology. 2nd ed. 1999 Lippincott Williams & Wilkins Philadelphia

Ruddy et al. Kelley's Textbook of Rheumatology. 6th ed. 2001 W. B. Saunders Company

Weissleder R, Wittenberg J, Harisinghani MG. The Primer of Diagnostic Imaging. 3rd ed. 2003 Mosby, Inc. Philadelphia

"Diagnostic Radiology/Musculoskeletal Imaging/Joint Disorders/Gout - Wikibooks, Collection of Open-content Textbooks." Wikibooks. Web. 19 Aug. 2010. <http://en.wikibooks.org/wiki/Diagnostic_Radiology/Musculoskeletal_Imaging/Jo int_Disorders/Gout>.

Ferguson, Mark. Gout. Print.

"Gout." Dr. Amilcare Gentili's Radiology Education Publications on the Internet" Web. 18 Aug. 2010. <http://www.gentili.net/Hand/gout.htm>.

Schlesinger, Naomi. "Diagnosis of Gout: Clinical, Laboratory, and Radiologic Findings." AJMC - American Journal of Managed Care. Web. 20 Aug. 2010. <http://www.ajmc.com/media/pdf/A141_Diagnosis>.

Smelser, Christopher D. "Gout." EMedicine - Medical Reference. Web. 19 Aug. 2010. <http://emedicine.medscape.com/>.

Web. 20 Aug. 2010. <http://www.gout.com/causes-triggers.aspx>.

Zayas, Vanessa M. "Gout: The Radiology and the Clinical Manifestations." Applied Radiology Online - The Journal of Practical Medical Imaging and Management. Web. 16 Aug. 2010. <http://www.appliedradiology.com>


Documents

KUSHAGRA , MS IV, MAMC, DELHI DR. GILLIAN ...eradiology.bidmc.harvard.edu/LearningLab/musculo/gupta.pdfKushagra, MAMC MS IV Gillian Lieberman, MD CARDIOVASCULAR DISEASES: HYPERTENSION