Gouts

Case Study

- Aayushi Singh, Tenzin Dolma, Ruchi Ravi, Kanika Dhawan

The story starts…

• A 46-year-old male presented to the emergency department with severe right toe pain.

• The patient was in usual state of health until early in the morning when he woke up with severe pain in his right big toe.

• The patient denied any trauma to the toe and no previous history of such pain in other joints.

• On examination, he was found to have a temperature of 38.2°C (100.8°F) and in moderate distress secondary to the pain in his right toe.

• The right big toe was swollen, warm, red, and exquisitely tender.

• The remainder of the examination was normal. Synovial fluid was obtained and revealed rod- or needle-shaped crystals that were negatively birefringent under polarizing microscope.

The laboratory investigation report revealed

• Hemoglobin – 8.9gm/dl,• ESR -124 mm at the end of first hour,• Leucocyte count -7400/cmm with normal

differential count• Random blood sugar-139 mg/dl• Creatinine- 1.6 mg/dl• Serum uric acid level- 10.9 mg/dl• His 24 hour urinary uric acid excretion was

446 mg/dl.• Serum calcium, phosphorus, LFT,

electrolytes and lipid profile were normal.

Signs and symptoms

• Warmth• Redness• The overlying skin may become

tense, warm, shiny, and red or purplish. 

• Swelling• Tophi

Pictures of symptoms

Swelling and redness Tophi

DIAGNOSIS OF ACUTE GOUTY ARTHRITIS

Synovial fluid analysis: Synovial fluid analysis can confirm the diagnosis by identifying needle-shaped, strongly negatively birefringent urate crystals that are free in the fluid or engulfed by phagocytes.

Tibia

• Serum urate level:- The serum urate level reflects the size of the extracellular miscible urate pool. The level should be measured on 2 or 3 occasions in patients ; if elevated , 24-h urinary urate excretion can also be measured. Normal 24-h excretion is about 600 to 900 mg on a regular diet. Quantification of urinary uric acid can indicate whether hyperuricemia results from impaired excretion or increased production . Patients with elevated urine excretion of urate are at increased risk of urolithiasis.

• Radiography: X rays of the affected joint may

be taken to look for bony tophi but are probably unnecessary if the diagnosis has been established by synovial fluid analysis.

Diagnosis of chronic gouty arthritis

Chronic gouty arthritis should be suspected in patients with persistent joint disease or subcutaneous or bony tophi. Plain X rays of the first metatarsophalangeal joint or other affected joint may be useful. Bony lesions are not specific or diagnostic but nearly always precede the appearance of subcutaneous tophi

Biochemical Basis

Increased consumption of purine-rich foods.Decreased excretion of uric acid by the kidneys, a complex process in which many things can wrong.Accelerated death or turnover of cells.Accelerated breakdown of purines uric acid production.Accelerated purine biosynthesis

Drug Treatment

Drugs used to increase the uric

acid secretionUricosuric drugs

( Probenecid, Sulfinpyrazone)

Drugs used to reduce inflammation

NSAIDAntiinflammatory:

ColchicineAnalgesic:

Indomethacin

Inhibiting synthesis of Uric acids

By inhibiting the enzyme Xanthine

Oxidase by Allopurinol

• Fluid intake ≥ 3 L/ day is desirable for all patients, especially those who chronically pass urate gravel or stones. • Alkalinization of urine (with K citrate, or acetazolamide) is also occasionally effective for those with persistent uric acid urolithiasis despite Hypouricemic therapy and adequate hydration. • Dietary restriction of purines is less effective, but high intake of high-purine food and alcohol (beer in particular) should be avoided. Purine rich foods include fish and organ meat like kidney, tripe, tongue and liver. •Carbohydrate restriction and weight loss can lower serum urate in patients with insulin resistance because high insulin levels suppress urate excretion. •saffron, garlic, apples and banana are best home remedies for gout. All these fruits and vegetables are rich in potassium that keeps the body rich with collagen. Collagen is a type of protein that strengthens the connective tissues between bones.

• Extracorporeal shock wave lithotripsy may be needed to disintegrate uric acid stones.

Kidney stones can sometimes be broken up by sound waves produced by a lithotriptor in a procedure called shock wave lithotripsy. After an ultrasound device or fluoroscope is used to locate the stone, the lithotriptor is placed against the back, and the sound waves are focused on the stone, shattering it. Then the person drinks fluids to flush the stone fragments out of the kidney, to be eliminated in the urine. Sometimes blood appears in the urine or the abdomen is bruised after the procedure, but serious problems are rare.

Thank You !!