Gout

Crise de goutte au niveau des mains

– Hyperuricemia (> 70 mg / L) is required to establish the diagnosis of gout but it is the presence of sodium urate crystals in synovial fluid that can confirm the diagnosis.

– Idiopathic hyperuricemia is the most common, especially in plethoric subjects

– The deficiency of the enzyme HGPRT whose full form is Lesch-Nyhan syndrome which results in infants with encephalopathy, abnormal movements and self-injurious behavior. In its incomplete form (X-linked) can be given a severe drop tophaceous among young males

– Other causes of hyperuricemia are: chronic renal failure by removing default, hematological malignancies by increased catabolism of nucleic acids

– Medications that can induce a gouty access are: low-dose aspirin, diuretics (especially thiazide), other (pyrazinamide, ethambutol, cyclosporine)

– The single-joint disease is the most common form in gouty access. The disease is most often at the métatarsophalagienne the big toe. Usually occurring in a man of sixty.

– With skin hyperaesthesia of significant inflammatory signs and a low-grade fever.

– The most affected joints after métatarsophalagienne big toe are: knee, foot, ankle, hand and elbow. Other: tenosynovitis, tendinitis (Achilles tendon) or boursites.

– The first access never starts with the upper limbs

– Gouty inflammation is recurrent

– The main triggers of gout are trauma, postoperative period, excess food or alcohol, the first less than a hyporuricémiant treatment and IDM.

– The dramatic efficacy of colchicine is an important diagnostic argument.

– The joint fluid (which must always be punctured) is inflammatory (> 2000 cells / mm3) and shows the presence of crystals of monosodium urate, usually intracellular (PNN). They are pathognomonic.

– These crystals are characterized by their slender appearance with pointed ends; negative birefringence.

– Standard during the first access normal radiographs (sometimes thickening periarticular soft tissues). The crystals of sodium urate are radiolucent.

– Faced with the clinical picture of febrile monoarthritis must think of septic arthritis

– Chondrocalcinosis (calcium pseudogout) is differentiated from the drops by the following: the achievement métatarsophalagienne big toe is more serious; rather elderly woman; Ca ++ pyrophosphate crystals (radio-opaque, rectangular aspect to square end). Colchicine is effective (but less than the drop).

– The drop in women before menopause is exceptional (mostly secondary).

– Drop polyarticular (usually high)

Gout in Hands
Gout in Hands

– The chronic form is seen during treatment misbehaving or not taken. We observe, tophi (cutaneous deposits of uric acid) that are painless, sometimes ulcerated skin.

– The election of tophi seats are the ears, elbows, feet and hands.

– Radiologically, urate arthropathy (chronic) are characterized by joint space narrowing, geodes (although limited) bone ends (urate deposition intraosseous) and sometimes a marginal osteophytes.

– We notice a predilection for cold regions of the body (ears, fingers, toes) or poorly vascularized tissue (cartilage or tendon)

– Renal manifestations of gout are: urolithiasis (calculated radiolucent) and gouty nephropathy (interstitial).

– Urolithiasis is favored by hyperuricemia, urinary acidity and reducing diuresis.

– The treatment of gouty access is via: colchicine (3 mg and lower)

– Colchicine to an anti-inflammatory action; it hinders phagocytosis of crystals of sodium urate by PNN decreasing mobility. She comes by on serum uric acid. Indomethacin and proposed in 2nd position.

– There is no need to start a urate-lowering therapy in the first gouty access

– Allopurinol (Zyloric) is a hypouricaemic which decreases uricosynthèse by inhibiting xanthine oxidase. It can be prescribed in patients with renal insufficiency. It is a lifelong treatment.

– The urate-lowering therapy should be started remotely from the gouty access (1 month) and under cover of colchicine first month.

– Do not forget that urate-lowering treatment can cause a gout access +++

– Indications of urate-lowering treatment: the existence of tophi (colchicine not stop until disappearance of tophi);recurrent gouty access, gouty arthropathy and gouty nephropathy.

– In case of kidney stones, must alkalize the urine with water from Vichy.

– Do not forget about lifestyle changes.