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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
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.
Lesch–Nyhan disease and variants
Published in William L. Nyhan, Georg F. Hoffmann, Aida I. Al-Aqeel, Bruce A. Barshop, Atlas of Inherited Metabolic Diseases, 2020
William L. Nyhan, Georg F. Hoffmann, Aida I. Al-Aqeel, Bruce A. Barshop
The clinical consequences of the accumulation of large amounts of uric acid in body fluids are manifestations classic for gout. These patients pass large quantities of urate crystals in the urine (Figure 65.9). Episodes of hematuria and crystalluria are the rule and may cause abdominal pain. Urinary tract calculi are regularly observed (Figures 65.10 and 65.11) and they may occur as early as the first months of life; they lead regularly to urinary tract infections. In the absence of treatment, urate nephropathy develops as a result of the deposition of sodium urate in the renal parenchyma. Death from renal failure at less than ten years of age was the expected outcome before the development of allopurinol. Tophi may be seen in those unusual patients who survive without treatment beyond ten years (Figure 65.12). Acute gouty arthritis is even more rare, but has occurred uniformly in untreated patients reaching adult life. Chronic tophaceous gout has been observed (Figure 65.13) [24].
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].
Case with long-standing gout showing various ultrasonographic features caused by monosodium urate monohydrate crystal deposition
Published in Modern Rheumatology Case Reports, 2020
Michito Murayama, Mutsumi Nishida, Yusuke Kudo, Takahiro Deguchi, Katsuji Marukawa, Yuichiro Fujieda, Nobuya Abe, Masaru Kato, Hitoshi Shibuya, Yoshihiro Matsuno, Tatsuya Atsumi
For a definite diagnosis, biopsy of the tophus at the dorsal surface of the right hand was performed. Polarizing microscopic examination demonstrated needle-like crystals (Figure 5), and the presence of MSU crystals in the tophus was confirmed. Thus, the 2015 American College of Rheumatology/European League Against Rheumatism classification criteria for gout were met [3], resulting in an initiation of non-steroidal anti-inflammatory drug (NSAID) and urate-lowering therapy thereafter. During the follow-up period, gouty nephropathy was suspected owing to the presence of prolonged albuminuria and a high creatinine level. Follow-up and consideration of kidney biopsy were performed for assessing renal dysfunction. NSAIDs were discontinued owing to the presence of renal dysfunction, and colchicine therapy was initiated because of the prolonged duration of the symptoms and elevated C-reactive protein level.
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].