Dr ali alkazzaz
Gout [old &new disease]History
• Identified in 2640 BC by the Egyptians• 5th century BC: Hippocrates identified podagra as “the unwalkable disease”
• Dominican monk Randolphus of Bocking (1197-1258) wrote gutta quam podagram vel articam vocant – ‘the gout that is called podagra or arthritis’
Nuki & Simkin, 2006. Arthritis Research & Therapy 2996, 8(Suppl 1):S1
History
Antoni van Leeuwenhoek described crystals from gouty typhus in 1679:“I observed the solid matter which to our eyes resembles chalk, and saw to my great astonishment that I was mistaken in my opinion, for it consisted of nothing but long, transparent little particles, many pointed at both ends and about 4 ‘axes’ of the globules in length. I can not better describe that by supposing that we with naked eye pieces from the horse-tail cut to a length of one sixth of an inch.”
Nuki & Simkin, 2006. Arthritis Research & Therapy 2996, 8(Suppl 1):S1
History
1961: McCarty and Hollander introduced polarizing light microscopy during synovial fluid analysis for acute or chronic arthritis:
• Different kinds of microcrystals:
Monosodium urate (MSU)
Calcium pyrophosphate (CPP)
Calcium apatite (apatite)
Calcium oxalate (CaOx)
Harrison’s Principles of Internal Medicine, 19e. 2015
The Gout by James Gilliray, Lettered with title and publication line: "Pubd. May 14th. 1799, by H. Humphrey 27 St James's Street".
Pathophysiology
4 stages:• Hyperuricemia without evidence of MSU deposition
• Cystal deposition without symptomatic gout
• Crystal deposition with acute gout flares
• Advanced gout characterized by tophi, chronic gouty arthritis and erosions
Dalbeth et al, 206. Lancet: 388: 2039-54
Dalbeth et al, 206. Lancet: 388: 2039-54
Neogi, T. Gout. N Engl J Med 364(5):443-452. February 3, 2011
Dalbeth et al, 206. Lancet: 388: 2039-54
Epidemiology
Prevalence in western countries: 3-6% in men and 1-2% in women
Prevalence in developing countries: < 1%
Men : women 2-6 times greater until age 70s.
US prevalence in 2007-08: 3.9%
Dalbeth et al, 206. Lancet: 388: 2039-54
Clinical Presentation
• Acute arthritis is the most common early manifestation of gout• Usually one joint initially, polyarticular acute gout in subsequent
• MTP join of first toe is often involved
• Tarsal joints, ankles and knees also commonly involved
• Finger joints in advanced
• Inflamed Heberden’s or Bouchard’s nodes may be first manifestation
• 1st episode of acute gouty arthritis begins at night with dramatic joint pain and swelling
• Joints become warm, red and tender and may mimic cellulitis
• Early attacks may subside spontaneously in 3-10 days
• Events that precipitate attack: dietary excess, trauma, surgery , excessive EtOH, hypouricemic therapy, MI and stroke
• After any attacks, pts may present with chronic non-symmetric synovitis – confused with rheumatoid arthritis
Lab Diagnosis
• Confirm diagnosis by needle aspiration of joint• MSU crystals – needle shaped intra- and extracellular
• Brightly birefringent with negative elongation
• Synovial fluid WBC 2k to 60k
• Effusions are cloudy
• Serum uric acid levels normal in acute attack
• 24h urine collection n useful for assessing risk fo stones from overproduction or under-excretion of uric acid
• Excretion of >800 mg per 24 h on regular diet,: overproduction of purine
Dalbeth et al, 206. Lancet: 388: 2039-54
Case Vignette
Neogi, T. Gout. N Engl J Med 364(5):443-452. February 3, 2011
Management Strategies in Patients with Hyperuricemia.
Neogi, T. Gout. N Engl J Med 364(5):443-452. February 3, 2011
Pharmacologic Management Options for Acute Gout Attacks.
Neogi, T. Gout. N Engl J Med 364(5):443-452. February 3, 2011
Pharmacologic Options for Hyperuricemia Therapy in Gout.
Neogi, T. Gout. N Engl J Med 364(5):443-452. February 3, 2011
Conclusions and RecommendationsNeogi, T. Gout. N Engl J Med 364(5):443-452. February 3, 2011
Conclusions and RecommendationsNeogi, T. Gout. N Engl J Med 364(5):443-452. February 3, 2011
Take-home Points