Gout Arthritis

Liyana Binti Mohd Arif

C111 12 813

Ruth Dea Sarah Amalia Hutabarat

C111 12 906

Case
Male, 56 years old came to hospital with chief complaint swellling
and pain on his left thumb since 1 day ago. Maximum pain in <12
hours. Patient also have fever since 1 day ago.
There is history of recurrent pain on left and right thumb since 1 year
ago. Patient also complain about the stiffness on his knee over the
past 6 months that last <15 minutes in the morning and history of
swelling and pain on his knee,
history of increased uric acid and took allopurinol 300mg once daily
these past 1 week.
Patient have history of hypertension and took valsartan 80 mg for his
hypertension, Diabetes Mellitus (-), history of heart disease (+) and
took aspilet these past 1 year for his heart disease, patient also have
history of alcohol consumption.

Physical Examination
Blood Pressure : 160/90 mmHg
Heart Rate : 90x/min
Respiratory Rate : 20x/min
Temperature : 37,6 Celcius
VAS : 3/10
Conjuctiva : Anemis (-)
Sclera : Icterus (-)
Ronkhi
Wheezing
BJ I/II, regular

Physical Examination
Rheumatologic Status :
G : Antalgic gait
A : there is no abnormality
L : Genu D/S : crepitation (+)
MTP I Pedis Sinistra : erythema (+), oedema (+), NT
(+), Tophus (+)
MTP I Pedis Dextra : Tophus (+)
S : Normal

Laboratory Findings
WBC
: 7,5 . 103
Hb
: 12,3
PLT
: 273 . 103
Uric Acid : 6
SGOT : 27
SGPT : 30
Ureum : 15
Creatinin : 2,5
eGFR
: 27,7

Diagnosis
Acute Gout, based on :
- Pain and swelling on MTP-1 pedis sinistra with maximal
pain < 12 hours.
- Fever
- Hyperuricemia
- History of recurrent pain at MTP-1
- MTP I Pedis Sinistra : erythema (+), oedema (+), NT (+),
Tophus (+)
- MTP I Pedis Dextra : Tophus (+)

Diagnosis
Secondary OA Genu ec gout arthtritis based on :
- Stiffness on his knees over the past 6 months last <15
minutes in the morning
- History of swelling and pain on his knees
- Genu dextra and sinistra : crepitation (+)
- history of hyperuricemia

Differential Diagnosis
Gout

Osteoarthritis

1. Presence of symptoms
affecting the whole body
(systemic)

Chills and a mild fever

along with a general
feeling of malaise may also
accompany the severe pain
and inflammation.

Systemic symptoms are not

present. Localized joint
pain (Knee and hips) but no
swelling pain severity is
important (mechanical,
inflammatory, nocturnal,
sudden)

2. Associated symptoms

Tophi may form. These are

large masses of uric acid
crystals, which gets
collected in the joints and
damage it.They also gets
collected in the bone and
cartilage, such as in the
ears.

(no systemic symps)

fatigue, muscle weakness,
fever. Bony enlargement,
deformity, instability,
restricted movement, joint
locked, sleep
dist,depression, comorbid
conditions (bursitis,
fibromyalgia, gout)

Disease Process

Metabolic Disease

Normal wear and tear

(chronic degenerative)

Pattern of joints that are

affected

Joint of the big toe most

commonly affected. other
joints affected are of ankle,
heel, knee, wrist, fingers,
elbow

Asymmetrical & may spread

to the other side. Symptoms
begin gradually and are often
limited to one set of joints,
usually the finger joints
closest to the fingernails or
the thumbs, large weightbearing joints,

Cause

Hyperuricemia
overabundance of
crystalline monosodium
urate (uric acid) deposits in
the blood and joint fluid.

Wear and tear associated

with aging or injury, also
caused by injuries to the
joints, obesity, heredity,
overuse of the joints from
sports

Age of onset

Usually over 35 years of

age in men and after
menopause in females

Over 50

Speed of onset

Sudden onset

Slow, over years

Further Anamnesis

History of present illness

Past medical history
Family history of disease
Socio- economic history

History Of Present Illness

Pain: location/onset/if there are any changes
after the break or getting worse/degree of pain
Trauma: fell/accident/occupation
Fever:
yes/no/when/characteristics/onset/pattern
Metabolic: weight loss/appetite/favourite
food/dietary habit
Daily activities: sports/dissability/handycap

Past Medical History

Aim: to determine other diseases before that can

cause the chief complaints.
Ask :
Is there a similar incident had occurred?
whether suffering from tuberculosis ,
chemotherapy , kidney failure
is there suffering from certain diseases such as
DM, renal disease?
Medication intake

 Family history of disease is important to

eliminate the possibility of hereditary diseases
and diseases that infected from family
members.
Social economy need to ask as a guideline for
the treatment or therapy until get the optimal
results.

Physical Examination
A. Generalized status
- Awareness: Compos mentis,
- BP:160/90 mm/Hg HR:90x/min RR:20x/min
T:37.6 C
- Weight:
Height:
- Skin: Anemis (-)
- Thorax :
Cor : Heart sound I/II, Reguler
Pulmo: Normal

B. Localized Status
1. Look/inspection
Are there signs of inflammation or injury
(swelling,redness, warmth)? Deformity? As
many joints are symmetric, compare with the
opposite side, observe the joint while patient
attempts to perform normal activity
2. Feel/Palpation :
Is there warmth? Point tenderness? If so, over
what anatomic structures?
3. Move: both active (patient moves it) and passive
(you move it) if active is limited/causes pain

Diagnostic Examination
Blood test for uric acid level
Normal value:
Female (2.4-6.0mg/dl)
Male (3.4-7.0mg/dl)

Urine test for uric acid level

Normal values: (250-750 mg/24 hours)
Examination of synovial fluid to recognize the presence
of crystals and to distinguish the types of crystals that are
present. Needle-like monosodium urate crystals are
associated with gout and calcium pyrophosphate crystals
are associated with pseudogout.

 Imaging test : X-rays

AP Photo Of The Pedis

Classic marginal
erosions (red arrow)
overhanging cortex
(blue arrow)

Diagnostic Criteria
Gold Standard for Gout Arthritis is there is crystal uric in tophus
We can use American College of Rheumatology (ACR) Criteria
a. Crystal uric in sinovial fluid
b. There is crystal uric in tophus
c. At least 6 of 12 clinical criteria , laboratory findings and
radiological findings
. there is more than one acute arthritis attack
.Inflamation max happen in 1 day
.Monoarticular arthritis
.Swelling and pain on MTP-1
.Unilateral arthritis involve MTP-1
.Unilateral arthritis involve tarsal joints
.Suspect there is presecnce of tophus
.Asymmetric swelling of joints (radiology)
.Subcortical cyst without erosion (radiology)
.Microorganism culture of sinovial joints (-)
Diagnosis cant be denied eventough uric acid level is normal

Pathomechanism of Problem List

The onset of attack correlate with the increasing
or decreasing of uric acid.
Early treatment with allupurinol which
decreasing uric acid can precipitate acute gout
attack cause the decreasing of serum uric acid
can trigger the releasing of crystal
monosodium uric from its deposit in tophus.
Alcohol consumption also can trigger the
fluctuation of uric serum concentration

Pathomechanism of Problem List

Inflammation : inflammation in Arthritis Gout caused by
accumulation of Monosodium Uric on joints, the mechanism
remain unknown but there are some factor that may involve like
chemical and celullar mediator
Celullar aspects of gout arthritis:
Macrophage in sinovium is the main cell in inflammation process
that can produce chemical mediator such as IL-1, TNF, IL-6, and
GM-CSF (Granulocyte Macrphage Colony Stimulating Factor).
These mediators can cause tissue damadge and activate other
inlammatory cells
Fever : Release of mediator will induce local inflammation and
systemic inflammation (febris) and also can cause tissue damadge.

Pathomechanism of Problem List

Pain : tophus in gout arthritis histopatologically
showed granuloma that surrounded by crystal
monosodium uric that can cause erosion of
cartilage and bone cortex around the tophus.
Crystal monosodium uric in tophus has a
needle shape that can cause pain.

Management
Non-pharmacologic teraphy:
Education
Diet
Rest

Management
Pharmacological teraphy:
Colchisine 0,5-0,6 mg 4-4x/daily, with max dose 6 mg
NSAID such as indometasin 75-100mg/day tappering
down after 5 days
For acute gout we cant give alopurinol if the patient
havent consume allopurinol before
Corticosteroid and ACTH used if kolkisin and NSAID
arent effective or patient have contraindication for
kolkisin and NSAID treatment
Allopurinol 100 mg/day

THANK YOU