Gout is one of the most dangerous underrated acute emergency in rheumatological diseases. CPPD disease is an another entity which is very much under-diagnosed in respect t OA

1. Crystal Arthropathies-
Gout & Pseudogout
Dr. Shinjan Patra,
3rd yr PGT in General Medicine, Midnapore Medical
College

2. Spectrum- Crystal Arthritis
• Gout- Mono-sodium urate crystal's
• Pseudo Gout- Calcium Pyrophosphate
crystals
• Calcium Hydroxyapatite crystals
• Others- Calcium Oxalate, Corticosteroid
esters

3. Gout

4. Introduction
• ‘King of diseases’ and ‘disease of the Kings’
• Galen (129-199 AD), an ex-gladiatorial
surgeon in the Pergamon arena in Asia Minor,
described gout as a discharge of the four
humors of the body in unbalanced amounts
into the joints (hence gout = gutta, a drop)
• first radiological description of gout was made
by Huber in 1896

5. Key definitive characteristics
• Recurrent attacks of acute arthritis where
mono-sodium urate crystals demonstrable-
sometimes leads to deformity/ crippling in
chronic stages
• Hyperuricemia ( >6.8 mg/dl exceeds the limit
of solubility, Men> 7mg/dl, Women 6 mg/dl)
• Renal disease involving glomerular, tubular &
interstitial tissues
• Uric acid nephrolithiasis

6. Hyperuricemia- Epidemiology
• Prevalence- 2.6% to 47.2% in various
population groups
• Gout incidence- 1% to 15.3%, increases with
serum urate level-
Serum Urate Level Annual Incidence rate of Gout
> 9 mg/dl 4.9%
7-8.9 mg/dl 0.5%
< 7 mg/dl 0.1%

7. Purine Metabolism
• Xanthine Oxidase oxidizes various purines
• It converts Hypoxanthine to Xanthine &
Xanthine to Uric acid
• AMP deaminase & 5’-nucleotidase critically
controls the nucleotide breakdown.
• Exogenous purine contributes to the total
body urate pool

8. Urate rich foods
• Red Meat
• Sea food- Shellfish
• Alcohol- Beer
• Fructose containing foods
• Artificial sweeteners

10. Renal handling of Uric acid
• Via specific Anion Transporters- URAT’s &
other Organic Anion Transporters carry urate
into PTC from luminal side.
• URAT1- Novel transporter at apical brush
border of proximal nephron
• Uricosuric agents (Estrogens, Fenofibrate,
Glycerol, Losartan, Probenecid, Salicylates)
inhibit (cis-inhibition) URAT 1
• Addl factors- Urine flow, Intravenous fluid
loading, anesthesia, endogenous steroids.

11. Classification of Hyperuricemia
• Primary-
• Secondary- Complete HPRT deficiency, Glu-6-P
deficiency, Fructose-1-P aldolase deficiency.
Undefined molecular defects Underexcretion/
Overproduction
PRPP synthetase variants Overproduction of Uric acid
HPRT deficiency, partial Overproduction of Uric acid

13. Pathogenesis of acute Gout

15. Acute Gouty Arthritis
• First attack usually between 40-60 years in
Male & >60 yrs in female
• First MTP joint- M/C, 90% affecting single joint
• Onset suddenly at night- joint becomes hot,
dusky red, swollen, extremely tender
• Provocative factors- Diuretic therapy,
cyclosporine, alcohol ingestion, surgery,
hemorrhage, infections.

16. Causes of Podagra
• Gout
• Pseudogout
• Hydroxyapatite crystals
• Reactive arthritis
• RA
• Septic arthritis

19. Intercritical & chronic tophaceous gout
• Even asymptomatic- MSU crystals found in
12.5 % to 90% of patients
• Hensch reported average 11.6 years between
first attack & development of chronic arthritis
• Main determinant- Serum urate level
• Generally produce irregular, symmetric,
moderately discrete tumescence of fingers,
hands, feet & knees.

20. Chronic tophaceous Gout

22. Associated co-morbid conditions
• Obesity, hypertriglyceridemia & over-eating
• DM- 2-50%
• Untreated HTN- 22-38%
• Increased atherosclerosis, CAD
• Increased hypothyroidism
• Rarely seen in RA, spondyloarthropathy, SLE

23. Renal manifestations
• Albuminuria- Mild/ Intermittent
• CKD- Urate > 13 mg/dl in men, > 10mg/dl in
women chronically
• Urate Nephropathy- Deposition of urate
crystals in interstitium of medulla/ pyramids
with surrounding giant cell reaction
• Tumor lysis syndrome
• Nephrolithiasis
• Familial juvenile hyperuricemic nephropathy

24. Diagnosis
• Complete blood count- Leukocytosis
• Raised Inflammatory markers- ESR, CRP
• Serum Uric acid- Not diagnostic but prognostic
value during urate lowering therapy
• Synovial Fluid Study- Leukocytes 2,000-
60,000/µL + Reduced Viscosity+ MSU crystals-
MSU crystals CPPD crystals
Long, needle shaped seen both intra &
extra-cellularly. Negatively birefringent
with compensated polarized light
Short, rhomboid/rodlike crystals with
weakly positive birefringent with
compensated polarized light

25. Radiographic features of Gout
• Bone erosions with
sclerotic margins.
• Thin, overhanging
calcified edge of bone-
specific marker
• Tophi calcification
• USG- Double contour
sign overlying the
articular cartilage
• CT- Urate crystals-
specific

26. Treatment- Asymptomatic
Hyperuricemia
• Underlying cause & associated secondary
conditions to be searched first
• No evidence that renal function adversely
affected by hyperuricemia
• Non-pharmacological ways of reducing urates
first
• Hypouricemic therapy to initiate- Male>
13mg/dl, Female-10mg/dl in asymptomatic

27. Acute Gouty Arthritis
• NSAIDS- Indomethacin (50 mg bid), Naproxen
(500 mg bid), Celecoxib (800 mg loading then
400 mg bid) recommended.
• Colchicine- 1 mg loading dose followed by 0.5
mg 1 hour later then as needed till acute
attack resolves (upto 0.5 mg tid)
• Oral Prednisolone- 0.5 mg/kg/day for 2-5 days
then tapper for 7-10 days OR
• If NPO then intra-articular/IV methyl-
prednisolone 0.5-2mg/kg or IM triamcinolone

28. • Combination Therapy- Severe attack with >7 in
VAS pain scale with more than 1 large joint
• Inadequate response- <20% improvement in VAS
pain scale within 24 hours- Then diagnosis should
be revised or add another agent
• Biologics- Anakinra/ Canakinumab uncertain
efficacy
• S/C synthetic ACTH at 25-40 IU initially
• Topical ice application with oral complementary
agents- Cherry juice, ginger, strawberries etc

29. Pharmacologic anti-inflammatory
prophylaxis
• Colchicine 0.5 mg bid or low-dose NSAIDS
(Naproxen 250 mg bid) + PPI to initiate along
with ULT
• Prednisolone 10 mg/day
• Duration- Until all symptoms resolved for at
least 6 months
or
3 months after achieving target serum urate
without tophi Or 6 months after achieving target
serum urate with tophi

30. Hypouricemic therapy
• Target level- 5-6 mg/dl
• Xanthise oxidase inhibitor- Allopurinol 300
mg/day to start & can be increased upto
800mg/day, S/E- GI intolerance, skin rashes,
TEN, BM suppression, hypersensitivity syn.
• Febuxostat- 40-80 mg/day, no hypersensitivity,
no adjustment in renal insufficiency
• Uricosuric agents to initiate who excrete
<800mg/day of uric acid + normal RF
• Probenecid + benzbromarone widely used

31. Diseases associated with
calcium pyrophosphate
dihydrate and basic calcium
phosphate

32. Introduction+ Epidemiology
• True prevalence not known
• Aged woman more affected
• CPPD + BCP crystal deposition- M/C calcium
containing crystal deposition disease
• Loose avascular tissue matrices of articular
hyaline cartilage, fibrocartilaginous menisci,
certain ligaments/tendons susceptible
• Knee/wrist/ankle M/C involved

33. CPPD- Pathogenesis
• Increased production of inorganic
pyrophosphate & decreased levels of
pyrophosphatases.
• Mutation in ANKH gene can increase transport
of pyrophosphate, reaction of ATP to
pyrophosphate catalyzed
• Release of CPP crystals to joint space produces
similar inflammatory reactions- Pseudogout

34. Associated Metabolic abnormalities
• Primary Hyperparathyroidism
• Hemochromatosis
• Hypophosphatasia
• Hypomagnesemia
• Myxedema
• Gitelman’s syn
To rule out CPPD crystals <50 yrs of age

35. Clinical features & diagnosis
• Osteoarthritic features + severe destructive
polyarticular arthritis
• Chronic symmetric synovitis
• Intervertebral disk, ligament calcification +
spinal stenosis
• Definitive diagnosis requires demonstration of
CPPD crystals
• Xray- Linear calcifications, sub-chondral bony
collapse, fragmentation, intra-articular
radiodense bodies

37. Treatment
• Rule out primary metabolic disorder by
assaying Ca, Po4, ALP, Mg, PTH, Iron profile,
TSH.
• NSAID’s + systemic/Intra-articular steroids in
acute pseudo gout
• Prophylaxis- Low-dose Colchicine
• Phosphocitrate, IL-1 antagonism, ANKH
channel blockade- Future therapy

38. Calcium apatite deposition disease
• Abnormal deposition of basic calcium
phosphate in areas of dystrophic calcification
or metastatic calcifications
• Extremely destructive chronic arthropathy
• M/C site- Bursae/tendons around knees,
shoulder, hips.
• Diagnosis- Crystals seen in electron
microscopy
• T/t- NSAID’s, colchicine + EDTA/Anakinra

39. Thank you……