Transcript Case 77: Gout

Case 77:
Gout
Presented by
Nicole Valdez
What is Gout?
 Characterized by hyperuricemia
(elevated plasmic uric acid
concentrations) and severe,
recurrent bouts of arthritis
caused by monosodium urate
(MSU) crystals deposited in the
joint spaces.
 Syndrome of abnormal purine
metabolism or excretion.
 Existed for over 2,000 years and
used to be known as “disease of
kings”
 Usually not life-threatening, but can
be painful, chronic, and disabling.
Pathophysiology
Patient’s Chief Complaints
“I woke up in the middle of the
night last evening and my right
big toe felt as if it was on fire. It’s
hot, swollen, and so tender that
even the weight of a blanket on it
is nearly intolerable. And there’s
no way that I can put a shoe on.”
History of Mr. J.H.’s Present Illness
 47 year old male
 Severe pain in right great toe – wore open toe sandals to
clinic
 Began previous evening and kept him up through the night
(acute onset)
 Taking extra-strength acetaminophen to keep the pain
under control
 Unable to bear weight on his right foot
 No history of injury to right foot
Past Medical History
 Hypercholesterolemia X 9 years
 Hypertension (HTN) X 9 years
 Transient Ischemic Attack
(TIA/Mini Stroke) 3 months ago,
appears to have no residual
neurological deficits
 Chronic sinus drainage/rhinitis
(S/P laryngoscopy)
 Allergies: NKDA
Medications
 Hydrochlorothiazide
(HCTZ) 25 mg po QD with
supper
 Aspirin (ASA) 325 mg po
Q AM
 Atorvastatin 10 mg po QD
 Flunisolide 2 sprays each
nostril QD
 Psudoephedrine 60 mg po
Q6h PRN
 Patient Case Question
 Why should the use of
psuedoephedrine by this patient
by carefully monitored by the
primary care provider?
 Patient already on
Flunisolide (corticosteroid)
for Nasal Rhinitis
 High use of a nasal
decongestant could be
detrimental.
Family History
 Educated throughout high school
 Mother living with type 2 DM
 Father died at age 68 from osteosarcoma
 Four adult children are all healthy
 No siblings
Social History
 Non-smoker
 Uses alcohol weekly
(averages 5-6
drinks/week)
 Married x2 with 4 adult
children (1 from 1st
marriage)
 Employed 17 years as a
truck driver and is
frequently away on the
road
 Lives with wife of 22
years, happily married
 Diet is heavy on red
meat and other highpurine foods
Causes and Risk Factors
 Genetics: ¼ people with gout have a postive family
history.
 Medical conditions and medications can increase
plasma and synovial urate concentrations and can
cause secondary gout.
 Diabetes mellitus, dehydration, sickle cell anemia, and kidney
disease
 Thiazide diuretics, low-dose aspirin, cyclosporine, and
tacrolimus
 Plasma uric acid levels begin to increase at puberty
in males and at menopause in females
 Adult males and postmenopausal females are at risk
Causes and Risk Factors
 Foods that are rich in
purines will increase
frequency of attacks
 Consuming too much
alcohol, especially beer can
inhibit renal excretion of uric
acid and can contribute to
gout
Causes and Risk Factors
 Obesity and trauma:
excessive weight can cause
trauma to weight-bearing
joints and lead to uric acid
deposits
 Starvation and rapid weight
loss can also increase
plasma uric acid
concentrations
 Great toe is subject to
chronic strain from walking
 Certain occupations, such as
truck driving, may cause
significant strain to the great
toe and cause an attack.
Review of Patient’s Systems
 Denies headache (HA) , dizziness, chest pain, SOB, and
generalized swelling or tenderness
 Weight has increased approximately 15 lbs in the last year
 No previous episodes of joint pain
Physical Examination
 General: White male
in mild acute distress
 Vital Signs:
 BP 145/85
 HR 92
 RR 17
 T 100.2 °F
 HT 6’1
 WT 225 lbs
 Patient Case Questions
 Has an optimal target blood pressure
management been reached in this
patient?
 Normal BP 120/80
 Normal BP for 47 yr old male is 127/84
 High BP for 47 yr old male is 139/88
 Other considerations: Patient has HTN
and patient is in pain
 Are any of the patient’s vital signs
consistent with a diagnosis of gout?
 Fever: Acute gout can cause a high fever
and leukocytosis
 HTN: Acute pain from gout can cause a
high BP by increasing sympathetic activity
 Obesity: Doubles gout risk.
Patient Case Questions
 Is this patient underweight,
 Identify 8 risk factors from the
overweight, obese or is this patient’s
case study that predispose the
weight considered normal and
patient to gout.
healthy for his height?

Alcohol
 Patient height: 6’1”

Diet
 Patient weight: 225 lbs

Weight gain
 BMI = 29.7 = Overweight

Male over 40
 BMI over 30 is obese

History of Hypertension

HCTZ medication (diuretic)

ASA medication

Truck driver
Physical Examination
 Neck/Lymph Nodes: Normal with no swelling,
thyromegaly, masses or jugular vein distention
 Eyes: Pupils equal at 3mm, round and reactive to light
and accomdation (PEARRLA). Normal funduscopic exam
 Lungs: Clear to Auscultation (CTA)
 Cardiac: Regular Rate and Rhythm (RRR). S1 and S2 with
no extra cardiac sounds. No gallops, rubs or murmurs
 Abdomen: Non-tender and non-distended. No
Hepatosplenomegaly (HSM). Normal bowel sounds.
Physical Examination
 Musculoskeletal/Extremities:
Pulses full throughout. Muscle
strength 5/5 throughout. Right
first metatarsophanlangeal
joint hot, tender,
erythematous, swollen
 Neuro: A&O x 3 . CNs II-XII
intact. Deep Tendon Reflex
Normal (DTRs 2+). Babsinski
(−)
Clinical
Manifestation
 Most common presentation:
sudden onset of pain and
swelling in
metatarsophalangeal joint of
great toe
 Other sites: ankle, wrist, knee
Clinical Manifestation
 Commonly confined to one
joint, but can progress
from one joint upward to
involve more joints.
 Single joint is warm,
erythematous, tender,
and characterized by
edema.
 Intercritical gout:
asymptomatic intervals
between acute attacks.
 Systemic signs of
inflammation: fever up to
102F, chills, leukocytosis,
and malaise
 Tophi: deposits of MSU crystals
at extra-articular sites, such as
the ear, along Achilles tendon,
or prepatellar bursa.
Characteristic of chronic gout
Laboratory Tests
 Main procedure: joint
aspiration (arthrocentesis)
 X-ray: acute attacks can’t
be seen, but chronic gout
appears as thickened regions
 Serum levels of uric acid
may not be elevated, but in
>95% of patients it is
elevated (>7.5mg/dL)
during an acute attack
 Erythrocyte
sedimentation rate (ESR)
can also be elevated during
episode of gout.
Laboratory Tests
 24 hour urinary
excretion of uric acid
>1100 mg
 Serum urate
concentration >13mg/dL
 Having both values
above the indicated
values gives the patient
a 50% probability for
developing urate kidney
stones.
Therapy
 Terminate acute attack
 Anti-inflammatory medications
 Prevent recurring attacks
 Diet
 Avoid hyperuricemic medications
 Use preventative medications:
colchicine, uricosuric drugs, and
allopurinol
 Gradual weight loss
 Prevent/reverse complications
associated with MSU crystal
deposits in joints
 Prevent kidney stones
Therapy
 Acute attack medications:
Non-steroidal antiinflammatory agents (NSAIDs)
 Indomethacin, ibuprofen, and
naproxen
 Aspirin is a NSAID, but should
be avoided
 Corticosteroids control most
attacks
 Available if you can’t take
NSAIDs orally
 Single joint attack  intraarticular administration of
triamcinolone
 Polyarticular gout:
methylprednisolone (IV or PO)
Laboratory Blood Test Results
Na
140 meq/L
K
4.2 meq/L
Cl
106 meq/L
HCO3 27 meq/L
Uric acid 13.1 mg/dL
Glu, fasting 120 mg/dL
Hb
15.6 g/dL
Hct
47%
BUN 14 mg/dL WBC 13.3 X 103/mm3
Cr
0.9 mg/dL • Neurophils
73%
•
•
•
•
Bands
Monocytes
Lymphocytes
Eosinophils
ESR
T chol
3%
3%
20%
1%
15 mm/hr
189 mg/dL
24 hr Urinary Uric Acid: 985 mg/day
X-Ray, Right Great Toe: Moderate, soft tissue edema; normal
joint space; no erosions or sclerosis
Laboratory Results
 Synovial Fluid
Examination: Significant
Polymorphonclear (PMN)
infiltration. Monosodium
urate (MSU) crystal
confirmed microscopically
with polarized light
Patient Case Questions
 Identify 5 laboratory test values that
are consistent with a diagnosis of gout?
 Synovial fluid analysis
 Presence of crystals
 Uric acid
 What is the significance of this
patient’s fasting blood glucose
concentration?
 Fasting = not eating
 Normal 60-110 mg/dL
 Normal 2.4- 7.4 mg/dL
 Patient 120 mg/dL
 Patient 13.1 mg/dL
 Undiagnosed diabetes
 ESR
 Normal (males): <10 mm/hr
 Patient 15 mm/hr
 CBC
 WBC (normal) 4,800-10,000/mm3
 WBC (patient) 13,300/mm3
 Differentiate between septic arthritis
and gout
 24 hr urinary uric acid
 Normal 250-750 mg/day
 Patient 985 mg/day
 Is there a need to adjust the
patient’s dose of atorvastatin
upward at this time? No
 Normal <200mg/dL
 Patient 189 mg/dL
Patient Case Question
Would probenecid, sulfinpyrazone, or allopurinol
be more appropriate medication for this patient?
Why?
 Since the patient is excreting >800 mg
urate/day, allopurinol is required.
 Allopurinol decreases the synthesis of
uric acid, rapidly lowers plasma urate,
 Probenecid is not used to treat
acute attacks, and instead is
used to prevent chronic attacks.
 Sulfinpyrazone is also used to
and facilitates mobilization of MSU
prevent attacks, but is also
while shrinking tophi.
contraindicated for this patient
 Allopurinol acts by inhibiting xanthine
oxidase, the enzyme that catalyzes the
conversion of hypoxanthine to xanthine
and xanthine to uric acid.
because of the high rate of
excretion of uric acid.
Sources
 Bruyere, Harold J., Jr. "Case Study 77: Gout." 100 Case
Studies in Pathophysiology. Philadelphia: Lippincott
Williams & Wilkins, 2009. 366-69. Print.
 “Crystal Induced Joint Disease Part 1” http://whatwhen-how.com/acp-medicine/crystal-induced-jointdisease-part-1/
 “ESR- The Test”
http://labtestsonline.org/understanding/analytes/esr/tab
/test/
 “Gout Explained Inside Out”
http://painbehindkneecure.com/gout-explained-insideout/
 “Gout Pictures Slideshow- Causes, Symptoms, and
Treatments of Gout”
http://www.webmd.com/arthritis/ss/slideshow-gout
 “Uric Acid Test” http://www.healthline.com/health/uricacid-urine#Purpose2