GOUT

Darmono SS
 GOUT
Gout : is a metabolic disease
Degenerative diseases due to inflamation
Joint and extra articular manifestation,
monoarticular, polyarticular, olygoarticular
Inflamation (tumor, rugor, calor,
functiolaesi, pain, stiffness)
Rheumatoid arthritis
Systemic catabolic state
 Etiology
Purine (uric acid) excess
Exessive ethanol ingestion,
Immobility due to chronic illness
Periarticular tophaceous deposits
 Epidemiology
Midle aged man and women
Mostly, aged women post menopausal
Result of body pool of urate
hyperuricemia (purine)
Characterized : episodic acute and
chronic arthritis
 Epidemiology
Prevalence : women 5 20 %
Decreased renal urate clearence
Renal insufficiency
Coincidence Hypertension due to mild
renal insufficiency
Increasing fluid cell count (leucocyt) >
2000 60.000
Cloudy synovial fluid inflamed fluid
 Pathogenesis
Increased uric acid serum
Inflamatory cytokines
Uricosuric
Risk os stones
Urinealysis serum creatine
Pathologic sequele
 Pathogenesis
Acute onset or chronically
Typically nocturnal monoarticular
Polyrticular longstanding diseases
Urate crystals in joint fluids
Tophi dx
Urate deposit in subcutaneus tissue,
bone, cartilage, joints and others.
 Pathogenesis
Deposition in kidney : uric acid
nephrolithiasis
Coincidence acute athritis and
periarthritis : MSU, calcium
pyrophosphate dihydrate, calcium apatite,
calcium oxalat, rheumatology,
crystalographic technique in synovial fluid
Infection and inflamation or non
inflamatory polyarticular acute gout
 Pathogenesis
Metatarsophalangeal joint of the toe, tarsal
joint, ankles, knees, finger joint
Features or manifestation: Inflamed
Heberdens or Bouchardis nodes
Begin night with dramatic joint pain and
swellin (red, tender, cellulitis)
 Pathogenesis
Deposition of monosodium urate (MSU) in
joint and connective tissue tophi
Deposition in kidney interstitium
 Crystal induce arthritis
Acute mono or poly Destructive
arthritis arthropaties
Bursitis Pseudo rheumatoid
Tendinitis arthritis
Enthesitis Ankylosing spondylitis
Tophaceous deposit Crown dens
Pecular osteoarthritis syndrome
Synovial Carpal turner
syndrome
osteochondromatosis
Figure 327-1 Extracellular and intracellular monosodium urate
crystals, as seen in a fresh preparation of synovial fluid, illustrate
needle-and rod-shaped strongly negative birefringent crystals
(compensated polarized light microscopy, 400x).
Figure 327-2 Intracellular and extracellular calcium pyrophosphate
dihydrate crystals, as seen in a fresh preparation of synovial fluid,
illustrate rectangular, rod-shaped, and rhomboid weakly positive
birefringent crystals (compensated polarized light microscopy,
400x).
Figure 327-3 A. Radiograph showing calcification due to apatite crystals
surrounding an eroded joint. B. An electron micrograph demonstrates dark
needle-shaped crystals within a vacuole of a synovial fluid mononuclear
cell (30,000x).
Figure 327-4 Bipyramidal and small polymorphic calcium oxalate crystals
from synovial fluid are classical finding in CaOx arthropathy (ordinary
light microscopy, 400x).
Figure 328- 2 chronic arthritis caused by Histoplasma capsulatum in the left knee. A.
A man in this 60s from El Savador presented with a history of progressive knee pain
and difficulty wlking for several years. He had undergone arthroscopy for a meniscal
tear 7 years before presentation (without relief) and had received several
intraarticular glucocorticoid injections. The patient developed significant deformity of
the knee over time, including a large effusion in the lateral aspect. B. An xray of the
knee showed multiple abnormalities, including severe medial femorotibial joint-space
narrowing, several large subchondral cysts within the tibia and the patellofemoral
compartment, a large suprapatellar joint effusion, and a large soft-tissue mass
projecting laterally over the knee. C. MRI further defined these abnormalities and
demonstrated the cystic nature of the lateral knee abnormality. Synovial biopsies
demonstrated chronic inflammation with giant cells, and culture gew H. capsulatum
after 3 weeks of incubation. All clinical cystic lesions and the effusion resolved after 1
years of treatment with itraconazole. The patient underwent a left total knee
replacement for definitive treatment. (courtesy of Fransisco M.Marty, MD, Brigham &
Womens Hospital, Boston; with permission).
 Purine sources
All meat (red meat)
Organ meat
Meat extract
Yeast
Beer
Alcoholic beverages
Bean, peanuts, spinach, mushrooms