House MD 1.3 Gout

Here I will give you 2 cases, so be patient.

Case 1 

A 25-year-old male comes to the ER with Nausea, Abdominal pain and hair loss. CBC shows decreased white cell count and he also has a history of cough for 1 week for which he had taken a course of medication given to him by his mother. He has no history of any other health issues. After checking his cough medication, the doctor rushes to look at his big toes, which happen to be completely normal. What do you think has happened here?

Answer: 

Alright, this is quite a long shot towards the answer. What actually has happened is that the pharmacist has messed up by giving him a drug called Colchicine instead of cough medication. This Drug is used to treat gout and causes side effects like:

• Nausea, vomiting, diarrhoea
• Bone marrow suppression
• Alopecia 

Thus, the Boy's condition is caused due to Colchicine and he can be treated with colchicine-specific fab fragments which increase urinary excretion.

Now, Let's learn in brief about Gout before we look at the second case. 

Gout is basically an arthropathy caused by increased monosodium urate crystals. 

Thus Purines are converted to Urate by Xanthine oxidase. and urate is either excreted by kidneys or converted back to purines by Purine Salvage Pathway. 

Excess of urate causes Gout as it gets deposited in the joints, most commonly in 1st Metatarsophalangeal joint (Base of the big toe). 

Major Causes Decreased urate excretion

• Renal failure
• Drugs: Thiazides, Aspirin Increased urate production
• Purine-rich food: Shellfish, red meat
• Tumour Lysis syndrome
• Lesch- Nyhan syndrome

Acute Gout 

There is inflammation of the joint. Podagra: Burning pain of the big toe may also involve other joints such as the ankle, knee, wrist and elbow.

Chronic Gout 

Asymptotic between acute attacks. There is deposition on urate as "TOPHI" seen on the big toe, ear, elbow and Achilles tendon.

Investigations

Increased Uric acid levels

Increased WBC, ESR and CRP

Synovial Fluid Analysis

• Increased WBC (predominantly Neutrophils)
• Monosodium urate crystals are seen
• Under polarised light: Negative Birefringence. (Parallel yellow, perpendicular blue)

Treatment:

Acute

Treatment:

Acute Gout

Manage the inflammation.

1st line: NSAIDs

DOC- Indomethacin

2nd line: Colchicine

mechanism of action:

Inhibition of

• microtubules

• chemotaxis

• phagocytosis

• leucocyte migration

If both NSAIDs and Colchicine are contraindicated or fail, then you may use Steroids.

Chronic Gout

• Decrease Uric acid synthesis

Xanthine Oxidase inhibitors:

    Allopurinol

    A/E: Steven Johnson Syndrome, Orotic Aciduria, Increased Azathioprine toxicity

    Febuxostat

• Uricosuric Drugs to increase excretion

    Probenecid

    Benzbromarone

• Drugs increasing urate metabolism (Uricase analogues)

    Pegloticase

    Rasburicase

NOTE: Drugs for treatment of Chronic Gout can precipitate acute gout, hence indomethacin or

Colchicine is always given alongside for the prevention of acute gout.

Now, let us come to

Case 2

A 22-year-old female presents with swelling and pain in the right big toe for 1 day. She also

has swelling in the knee.

investigations reveal normal uric acid levels, but liver enzymes are elevated. She gives a history

of hemochromatosis.

synovial fluid analysis reveals " WEAKLY POSITIVE BIREFRINGENCE".

An x-ray shows the below finding.

What is your diagnosis?

Answer:

The picture of Podagra might tempt you to think this is gout.

But the other findings such as Positive birefringence, chondrocalcinosis in the knee joint, absence

of hyperuricemia and associated history of hemochromatosis strongly suggest the diagnosis 

be "Pseudogout".

Pseudogout, which is also called Calcium Pyrophosphate Deposition Disease(CPPD) is caused

due to deposition of Calcium Pyrophosphate crystals in the joints and is clinically similar in

presentation to gout but it usually affects multiple joints.

its treatment is the same as that of acute gout.