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Crystalline Arthritis
Published in Jason Liebowitz, Philip Seo, David Hellmann, Michael Zeide, Clinical Innovation in Rheumatology, 2023
In 2020, the American College of Rheumatology updated guidelines for the treatment of gout.28 The 2020 guidelines differ from earlier ones in considering costs of care and including the input of gout patients themselves. Highlights include a strong recommendation for a treat-to-target strategy. The 2020 guidelines conditionally recommend continuing ULT indefinitely, pointing to observational data that most patients will experience recurrent flares when ULT is discontinued. Additionally, the guidelines no longer specify a urate goal of less than 5 mg/dL for those with more severe disease, owing to a lack of high-quality evidence. Research supports more rapid dissolution of tophi at lower serum urates; however, the risk-benefit ratio of targeting a lower goal has not been substantiated. Dose titration, per 2020 ACR guidelines, should be on the scope of “weeks to months, not years.” This is an example of how the 2020 guidelines are less prescriptive and promote shared decision-making between patients and providers compared with prior guidelines.29
Hands & Feet
Published in Richard Ashton, Barbara Leppard, Differential Diagnosis in Dermatology, 2021
Richard Ashton, Barbara Leppard
These are hard white or cream coloured papules or plaques due to deposition of sodium urate crystals in the dermis. They occur on the helix or antihelix of the ear (see p. 120), and on the dorsum of the hands and feet. Patients with tophi will have raised uric acid levels in the blood and are likely to suffer from painful joints especially of the big toe.
Paper 4
Published in Aalia Khan, Ramsey Jabbour, Almas Rehman, nMRCGP Applied Knowledge Test Study Guide, 2021
Aalia Khan, Ramsey Jabbour, Almas Rehman
Other drugs which may induce hyperuricaemia include: cytotoxics, pyrazinamide and ethambutol. Characterised but not always defined by hyperuricaemia, gout results from a disorder of purine metabolism, which causes urate crystal deposition and painful synovitis. Cartilage damage may occur and large urate deposits are known as tophi. Acute attacks are treated by rest, fluids, stopping any causative drugs and administering NSAIDs, e.g. diclofenac; however, steroids may be necessary. Maintenance treatment includes lifestyle modification, e.g. reducing alcohol intake and making dietary changes, and uricosuric drugs, e.g. allopurinol, which are not effective acutely.
Volumetric reduction and dissolution prediction of monosodium urate crystal during urate-lowering therapy – a study using dual-energy computed tomography
Published in Modern Rheumatology, 2021
Charlotte Shek Kwan Chui, Alexander Kai Yiu Choi, Marianne Man Yan Lam, Tze Hoi Kwan, On Chee Li, Yongmei Leng, Denise Long Yin Chow
DECT scan was performed on regions that were most severely affected clinically regardless of frequency of gouty attack. In our series, patients had more upper limb functional complaints than lower limb, accounting for more hands and wrists scanned than feet. Apart from superficial tophi that were easily picked up, significant portions of deep tophi at the carpal tunnel and flexor tendons were identified by DECT. While superficial tophi represent biased samples of the total MSU load in a region, DECT measures the total MSU volume in the region, part of which may not present as tophi [12,22]. In the present series, 22 patients (73%) had complete resolution of superficial tophi. On DECT, 18 patients (60%) achieved 90% MSU dissolution while only 5 patients (17%) achieved 99% dissolution. In a study with patients well-managed by ULT (SU < 6.0 mg/dl) without tophi, 47% had MSU crystal detected on DECT with volumes ranging from 0.01 to 0.89 cm3 [16]. In another study looking at gout patients fulfilling remission criteria and no tophus, MSU crystal of up to 1.23 cm3 was detected in 64% of them [25]. It was suggested that tophus size correlated poorly with the true MSU load. On the other hand, tophus contains both urate and non-urate (soft tissue) portions [22,26]. The MSU deposition is directly affecting the soft tissue volume of tophus [22]. They in turn have independent effects on bone and joint erosion [22,27]. Therefore, monitoring of MSU dissolution by DECT is more relevant in the treatment of tophaceous gout than tophus measurement [28].
Intra-osseous tophaceous gout of a bipartite patella mimicking aggressive bone tumour
Published in Modern Rheumatology Case Reports, 2021
Fidelis Marie Corpus-Zuñiga, Keiichi Muramatsu, Ma. Felma Rayel, Yasuhiro Tani, Tetsuya Seto
Imaging findings for gouty tophi tend to be non-specific [13]. On radiographs, tophi may be seen as intra-articular or peri-articular lesions, which may or may not accompany signs of arthritis. On MRI, tophi characteristically appear as homogenous to heterogeneous low to intermediate signal intensity masses on T1- and T2-weighted images. On images with gadolinium contrast, tophi may be seen as homogenous, heterogeneous or peripheral enhancing lesions [11,13]. The imaging findings of CT and MRI for our patient appear to be inconclusive. A rapidly enlarging lesion in a span of less than 6 months is also less characteristic of gout and more of a neoplastic process. Ideally, a biopsy should have been performed pre-operatively in order to rule out malignancy or infection, and to establish a tissue diagnosis for proper surgical planning. However, based on the patient’s clinical picture and imaging, there is high clinical suspicion for a benign lesion. It has been decided to go directly with complete removal of the lesion via curettage and collect this specimen for histopathology in one sitting [14,15].
Gouty tophus without gout attacks treated using a reversed digital artery flap
Published in Case Reports in Plastic Surgery and Hand Surgery, 2020
Yukako Okuhara, Keisuke Shimbo, Shogo Nagamatsu, Kazunori Yokota
Surgical treatment for tophus has become unpopular. Surgical treatment of gout is an ancient remedy; before the emergence of effective medical treatment, surgery was frequently performed. It was most commonly recommended for cosmetic reasons or for the removal of large deposits of sodium urate. Tophaceous gout results from prolonged hyperuricemia, and medications for lowering uric acid levels are usually effective. Therefore, gouty tophus is usually treated conservatively with drugs. There is a possibility of its disappearance, specifically the reduction of the tophus, by maintaining the serum uric acid level at <6.0 mg/dL, which is considered to also prevent recurrence. The indications for surgical interventions are impairment of the function of tendons and joints, skin ulceration or necrosis over the tophi, local infections or septicaemia caused by tophi, nerve compression, presence or absence of a diagnosis of malignancy, and cosmetic reasons. Although controlled trials comparing medical and surgical therapies are lacking, surgery can potentially restore function faster than medical therapy and prevent complications in some individuals with persistent tophi. The treatment preference should be based on the patient’s condition [6].