Crystalopathies

1. Crystalopathies Joanna Zalewska

2. Gout • Inflammatory arthritis with crystallization of monosodium urate crystals in joint or soft tissue

3. Classification • Asymptomatic hyperuricaemia • Acute gout • Recurrent attacks • Chronic tophaceous gout • Urolithasis

4. Risk factors • Overall body weight or central obesity • Very rapid weight loss through dieting • Hypertension • Loop and thiazide diuretics • Alcohol

5. Key features in history- acute • First attacks are usually monoarticular with the metatarsophalangeal joint of the great toe • Other joints- wrist, elbow, small joints of hand • Attacks self-limiting after 5-7b days • Onset is often lateat night or in the early morning • Before- surgery, dehydratation, alcohol intake

6. Key features in history- chronic • Polyarticular • Repeated attacks get closer together and become more prolonged • Repeated attacks may result in deformity, reduced rangeof joint movement or chronic pain • Tophi

7. Examination - acute • A hot, swollen, tender joint • Involvement of soft tissues - chronic • Deformation of joints • Tophi- subcutaneously, in bones and organs- painless (white, creamy discharge)

8. Tests • Leucocytosis- acute goat • Elevation of ESR and CRP • Serum creatinine • Serum urate • Blood cultures • Synovial fluid- crystals of monosodium urate • Radiographs- unhelpful in early gout, in late- calcification and erosions (head of the first metatarsal) • Ultrasound- synovitis

9. Treatment • Asymptomatic hyperuricaemia does not require treatment • Septic arthritis should be considered • Terminate the attack as soo as possible • Ice therapy, NSAIDs, colchicine, glucocorticosteroids

10. NSAIDs • Indometacin- the traditional NSAIDs • Naproxen in Poland • NSAIDs should be avoided in patients with heart failure, renal insufficiency, history of previous peptic disease Colchicine • Most patient respond within 18 h • Dose 500 ug 2-4 times daily (diarrhoea)

11. Glucocorticosteroids • Useful in patients who cannot tolerate or not improving with NSAIDs or colchicine • Intra-articular injections are effective in monoarthritis or oligoarthritis • Oral, intramuscular or intarvenous • Prednisolone 20- 50 mg daily for 2 weeks

12. Inhibitors of the enzyme xanthine oxidase- long term treatment Allopurinol • should not be commenced during an acute attack, but should be introduced 1-2 weeks later • Low dose of colchicine (500 ug) for 6 months following introduction of allopurinol to avoid attacks • The dose should be increased by 50- 100 mg in response to changes in serum urate levels • Side effects- rash, allergic reaction, fever, mucositis, dermatitis Febuxostat

13. Follow-up • Lifestyle- diet (avoid food with very high purine content as shellfish, sardines, meat, avoid alcohol, drink 2 l of fluid) • Control BP, serum urate, renal function, glucose

14. Calcium pyrophosphate dihydrate disease (CPDD) • Chondrocalcinosis/ pseudogout • Deposition of calcium pyrosphoshate dihydrate crystals • Diagnostic- polarized light microscopy- gold standard • Women age 70

15. Tests • Leucocytosis- acute attacks • CRP, ESR elevation • Creatinine • joint aspiration- rhomboid-shaped crystals under polarized light- the most important • Radiology- medial and lateral menisci of the knee, triangular cartilage of wrist, symphis pubis

16. Treatment • NSAIDs • Intraarticular injection of glucocorticosteroids • Rest the joint • Low dose of colchicine (1 mg/ day) • Low dose of prednisolone • DMARD • Joint replacement surgery