GOUT........

<p>GOUT</p><p>Definition<br> : A group of conditions with deposition of mono-sodium-urate-monohydrate crystals in the connective tissues, due to a hyperuricemic state, causing arthritis, tenosynovitis, bursitis, tophaceous deposits, urolithiasis, and urate nephropathy.</p><p>Epidemiology :</p><p>Affects both males &amp; females. Males commonly post-pubertal and females post-menopausal.</p><p>Etiology :</p><p>May be due to either increased production (25%) or decreased excretion (75%) of uric acid from the body.</p><p>Decreased excretion of uric acid :</p><p>Renal failure</p><p>Drugs - diuretics, salicylates (aspirin)</p><p>Lead poisoning</p><p>Hyperparathyroidism</p><p>Myxedema</p><p>Lactic acidosis due to any cause -</p><p>Starvation</p><p>Alcohol</p><p>Exercise</p><p>Vomiting</p><p>Toxemia of pregnancy</p><p>Due to inherited defect in excretion.</p><p>Overload of uric acid<br> (if renal function is normal - hyperexcretors of uric acid).</p><p>Increased synthesis of purines de novo (faulty nucleotide synthesis --loss of negative feedback).</p><p>Increased turnover of purines -</p><p>Pathology :</p><p>Urate crystal deposition in joints</p><p>2ndary degenerative changes with inflammation --- destruction of joint.</p><p>Acidic urine --- urate ppts esp in hyperexcretors of uric acid --- urolithiasis.</p><p>Urate crystals in soft tissue --- chalky deposits with later 2ndary changes -- Tophi / tophaceous deposits.</p><p>C/F :</p><p>Gouty arthritis<br> :</p><p>ACUTE gouty arthritis<br> :</p><p>Commonly acute attack occurs 1st in MTP joint of great toe.</p><p>Joint swollen, hot, red, tender, with restricted movements.</p><p>May be accompanied with fever, malaise, leucocytosis.</p><p>Subsides even without treatment spontaneously.</p><p>Recurrent attacks in most patients at increasing frequency and increasing duration --- attacks blend into each other --- chronic &quot;gouty&quot; arthritis.</p><p>Precipitating factors<br> -</p><p>Sudden rises in urate - dietary excess, alcohol, diuretics</p><p>Sudden falls - Start of therapy.</p><p>Chronic arthritis with tophi<br> :</p><p>Recurrent acute attacks</p><p>Bony erosion &amp; joint destruction</p><p>Tophi deposited - can be found in ear cartilage, bursae, tendon sheaths.</p><p>Progressive limitation of joint function.</p><p>Urolithiasis -</p><p>Common in high excretors</p><p>Common in hotter climates</p><p>With uricosuric drugs</p><p>With acidic pH of urine - diarrhea, ileostomy.</p><p>Urate nephropathy -</p><p>D.t. a combination of renal tubular obstruction, urolithiasis, hypertension, DM, 2ndary pyelonephritis.</p><p>Associated conditions -</p><p>Obesity</p><p>DM</p><p>Hyper lipoproteinemia type IV</p><p>HT</p><p>IHD</p><p>Pseudogout (D/D) :</p><p>Rheumatoid arthritis</p><p>Chondrocalcinosis - calcium pyrophosphate dihydrate (CPPD) deposition.</p><p>Investigations :</p><p>S. uric acid<br> - not very useful because -</p><p>may be asymptomatic hyperuricemia.</p><p>Normal serum uric acid levels<br> - 2.5-8.0 mg% in males &amp; 1.5-6.0 mg% in females.</p><p>Acute attack may occur with normal uric acid.</p><p>X-Ray of joint<br> - no characteristic changes</p><p>Synovial fluid<br> - Variable color, viscosity , under polarized light shows urate crystals.</p><p>Therefore <br>diagnosis is mostly clinical<br>.</p><p>General Treatment :</p><p>Avoid excess purine intake - meat.</p><p>Avoid excess alcohol - ppts acute attack</p><p>Weight loss in obese patients.</p><p>Avoid starvation - ppts lactic acidosis - Acute attack</p>