1

GOUTY ARTHRITIS
Christiana Vida C. Montelibano
1st year Internal Medicine Resident
 Introduction
2

 Gout is a disabling and common disease

 Prevalence ranges from 0.9% to 2.5%
 Despite effective treatments, it is still often
misdiagnosed and management remains suboptimal
 Objectives
3

 To discuss a case of a patient with gouty arthitis

who presented with joint pain & swelling
 To discuss the approach to a patient with arthritis
 To discuss briefly gouty arthritis with regard to
background, clinical presentation, diagnosis, and
management
 To discuss the updated European guidelines for the
management of gouty arthritis
4

A.D.
56 year old
Male
RPV

Chief Complaint:
Joint Pain
5

• Heavy alcoholic beverage drinker

• Ankle pain: intermittent, non radiating, increasing in severity,
relieved by pain relievers, with difficulty ambulating
• Consult done. Dx: Gouty arthritis; Prescribed allopurinol taken only
1999 when symptomatic

• Persistence of pain: intermittent pain, progressively increasing in

intensity, usually controlled by pain relievers
• 2014: (+) hard non-tender nodules on his right elbow, and both
Interval knuckles
history
 History of Present Illness
6

• Swelling and warmth of his joints most

especially his Left knee
• Accompanied by severe pain described as
1 day sharp, graded 9/10, non radiating, lasting
prior to several hours, with difficulty in mobility
• Self medicated with dolcet tab and mefenamic
admission acid, no relief
• Persistence of joint pain and increasing severity
led to consult and subsequent admission
 Past Medical History
7

 Current Illnesses: (-) Hypertension, (-) Type 2

DM, (-) PTB, (+) Urate Nephropathy (2015)
 Previous hospitalizations: 2015 – VMMC, Gouty
arthritis in flare
 Previous surgeries: none

 Previous BT: none

 Known allergies: none

 Current medications: Febuxostat 40mg/tab,

once daily, poorly compliant
 Family History
8

 (+) T2 DM – brothers
 (+) Leukemia – daughter and nephew

 (-) HPN, (-) PTB

 (-) heart disease, kidney disease, liver disease,

pulmonary disease
 Personal and Social History
9

 Non-smoker
 Previous heavy alcoholic beverage drinker
 all
types of liquor (usually beer), until inebriation,
weekly, for 15 years
 Works as a fisherman with income of
Php10,000/month; Lives in a 2 room house in a
cramped community by the ocean
 Married, wife works in Manila as a domestic
helper, 3 children; born-again Christian
 Review of systems
10

 General: (-) weight loss/gain, (-) dizziness, (-) headache

 Integumentary: (-) jaundice, (-) rash, (-) skin lesion
 EENT: (-) blurring of vision, (-) decreased hearing, (-) ear
pain, (-) tinnitus, (-) nasoaural discharge, (-) epistaxis, (-)
gum bleeding, (-) sore throat
 Respiratory: (-) colds, (-) cough, (-) hemoptysis, (-)
dyspnea
 Cardiovascular: (-) chest pain, (-) palpitations, (-)
orthopnea
 Review of systems
11

 Gastrointestinal: (-) vomiting, (-) diarrhea,

(-) constipation, (-) hematemesis, (-) melena, (-) dysphagia
 Genitourinary: (-) dysuria, (-) hematuria, (-) frequency, (-

) urgency, (-) hesitancy, (-) flank pain

 Musculoskeletal: (-) myalgia, (-) joint pains, (-) edema

 Endocrine: (-) polyphagia, (-)polydipsia, (-)polyuria,

(-) heat or cold intolerance

 Hematopoietic: (-) easy bruising, (-) gum bleeding
 Physical Examination on Admission
12

 Conscious, coherent, not in distress, normosthenic,

ambulatory, in mild to moderate pain
 120/80mmHg, 70bpm, 18cpm, 36.8°C, O2 sat 98%
 Weight: 60 kg Height: 165.2 cm, BMI: 22.7
 HEENT: Pink palpebral conjunctiva, anicteric sclera, nasal
septum midline, dry tongue and lips
 Neck: supple neck, no palpable cervical lymph nodes, no
neck mass, no neck vein distention
 Physical Examination on Admission
13

 Chest: Symmetrical chest expansion, clear breath sounds

 Heart: Adynamic precordium, normal rate, regular
rhythm, no murmurs
 Abdomen: Flat abdomen, soft, nontender, tympanitic on
all quadrants, no hepatosplenomegaly
 Genitourinary: No CVA tenderness
 Extremities: Pulses full and equal on all extremities, no
edema, (+) multiple tophi on both knuckles, elbows, knees,
ankles and feet, (+) tenderness & swelling of bilateral wrists,
elbows, knees, ankles, warm to touch, (+) ballottement of left
knee, (+) painful on passive ROM
 Neurologic Examination
14

 Conscious, coherent, oriented to 3 spheres

 Cranial Nerves
 CN I: Not assessed
 CN II, III: 2-3 mm ERTL
 CN III, IV, VI: Intact EOM’s
 CN V, VII: (+) corneal reflex, no facial sensory deficit, no facial asymmetry
 CN VIII: Gross hearing intact
 CN IX, X: (+) gag reflex
 CN XI: Can shrug, can turn head side to side
 CN XII: Tongue in midline
 Cerebellar: can do APST, can do Finger to nose test
 Meninges: no nuchal rigidity; (-) Brudzinski; (-) Kernig
 DTR: (2+) for biceps, patellar, and knee reflexes
 Motor: 5/5 on all extremities
 Sensory: 100 % in all extremities
 No babinski
 Salient Features
15
Subjective
 56/M/RPV
 Known Chronic
Tophaceous gout
 1 day history of joint
pain & swelling (acute)
Objective
 (+) tenderness &
swelling of bilateral
wrists, elbows, knees,
ankles, warm to touch
 (+) multiple tophi on
both knuckles, elbows,
knees, ankles and feet
 (+) ballottement of
Left knee
 Differential Diagnosis: Algorithm
16

Source: Harrison’s 19th Ed.

 Differential Diagnosis
17
Infectious Arthritis
 Fever + arthritis
 Great tenderness/pain with
any movement
 May have RA also
 Source: skin/lungs
 Usually
staphylococcus/gonorrhea
 Purulent invasion of joint by
infectious agent
 Risk: artificial joint
Reactive Arthritis
 Inflammatory oligoarthritis
 Weight bearing joints
 Tendon insertion inflammation
 Dactylitis (sausage digits)
 Extraarticular manifestations
(conjunctivitis, urethritis,
stomatitis, psoriaform skin)
 Infection 3 weeks prior
 Differential Diagnosis
18
Pseudogout
 Males = females
 Older age group
 Acute/insidious onset
 Crystal: (+) bifringence,
rhomboid, calcium
pyrophosphate
 Knee, hand, polyarticular
 Radio: chondrocalcinosis,
OA
Gout
 Males > females
 Middle aged males, post-
menopausal women
 Acute
 Crystal: (-) bifringence,
needle shaped, monosodium
urate
 1st MTP, foot
 Radio: holes in bones
 Tophi: pathognomonic
 Initial Impression:
19

Acute Gouty Arthritis in Flare

on top of Chronic Tophaceous Gout
 Initial Work-up
20

 Hematology
NV 4/21
Hgb 140 – 180 mg/dL 104
Hct 0.40 – 0.54 0.31
WBC 5-10x109/L 11.3
Stab 0.01 – 0.05 0.04
Segmenter 0.60 – 0.70 0.78
Lymphocyte 0.20 – 0.40 0.15
Monocyte 0.01 – 0.06 0.01
Eosinophil 0.01 – 0.05 0.02
Platelet Count 150 – 450 x 109/L 250
 Initial Work-up
21

N.V. 4/21
BUN 2.1 – 7.1 mmol/L 8.7
Crea 62 – 106 umol/L 167
ECC 38.8
SGPT 0 – 41 U/L 14
SGOT 0 – 40 U/L 21
Albumin 35 – 52 g/L 33
Total Calcium 2.2 – 2.6 mmol/L 2.2
Phosphorus 0.9 – 1.5 mmol/L 1.0
Sodium 136 – 145 mmol/L 131
Potassium 3.5 – 5.1 mmol/L 3.9
Chloride 98 – 107 mmol/L 108
RBS 5.9
BUA 203 – 417 umol/L 497
 Initial Work-up
22

 ECG: Normal Sinus Rhythm

 CXR: Normal
 Impression:
23

Acute Gouty Arthritis in Flare on top of Chronic

Tophaceous Gout
Chronic Kidney Disease G3A secondary to Urate
Nephropathy
 Course in the ward
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Upon Admission (4/21/17)

P: • Low purine diet
• Hydrated with PNSS
• Meds:
 Colchicine 0.5mg/tab OD
 Prednisone 5mg/tab BID
 Pain Medications: Paracetamol 1g/tab Q12 & Tramadol 50mg/tab Q8
• Cold compress
 Course in the ward
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2nd – 5th Hospital Day (4/22-26/2017)

S: (+) Persistence of joint pain, gradually decreasing in intensity

O: (+) Persistence of joint inflammation and swelling, especially of the left knee

P: • Continued Meds:
 Colchicine 0.5mg/tab OD
 Prednisone 5mg/tab BID
 Pain Medications: Paracetamol 1g/tab Q12 & Tramadol 50mg/tab Q8
• Cold compress
 Course in the ward
26

7th Hospital Day (4/27/2017)

S: (+) Persistence of joint pain, gradually decreasing
in intensity

O: (+) Persistence of joint inflammation and swelling,

especially of the left knee, (+) ballottement

P: • Arthrocentesis: 40cc of synovial fluid was

aspirated with (+) minimal string sign
• Intraarticular methylprednisone 40mg/mL, 1 mL
was instilled
• Meds:
 Colchicine 0.5mg/tab OD
 Prednisone 5mg/tab BID
 Pain Medications: Paracetamol 1g/tab Q12 &
Tramadol 50mg/tab Q8
• Cold compress
 Course in the ward
27

8th – 10th Hospital day (4/28-30/2017)

S: Improvement in symptoms, able to ambulate without pain

O: Joint swelling and imflammation of the left knee decreased significantly

P: • Discharged
• Prescribed Febuxostat 40mg/tab once a day as maintenance
• Advised: avoid fruits and fruit juice, increase water intake
• For follow-up at MACC on May 16 with repeat BUA results
• For monitoring of creatinine
 Final Diagnosis
28

Chronic Tophaceous Gout

Chronic Kidney Disease G3A secondary to Urate
Nephropathy
29 Approach to Patient with Arthitis
30

Source: Harrison’s 19th Ed.

31

Source: Harrison’s 19th Ed.

 Simpler approach:
32

Source: Harrison’s 19th Ed.

33 Gouty Arthritis
 Gout
34

 Metabolic disease due to increased body pool of

urate
 Affects middle-aged men / post-menopausal
women
 Characterized by episodic acute and chronic
arthritis
 Caused by deposition of MSU crystals in joints and
connective tissue tophi
 Risk for deposition in kidney interstitium or uric acid
nephrolithiasis
 Clinical Presentation
35

 Acute arthritis is the most common early

clinical manifestation
 Initially monoarticular, but may become
polyarticular
 Most common sites:
 MTP of 1st toe
 Tarsal joints, ankles, and knees
 Fingers in elderly or with advanced disease
 Inflamed Heberden's or Bouchard's nodes
 First episode:
 Begins at night with dramatic joint pain and
swelling
 Joints rapidly become warm, red, and tender
(mimics cellulitis)
 Clinical Presentation
36

 Early attacks subside spontaneously within 3-10

days
 Intervals of varying length with no residual
symptoms until the next episode
 Precipitating events: dietary excess, trauma,
surgery, excessive ethanol ingestion, hypouricemic
therapy, and serious medical illnesses such as MI
and stroke
 May eventually become chronic gouty arthritis 
Periarticular tophaceous deposits
 Diagnosis
37

 Serum uric acid

 Diagnosis & monitoring response to therapy
 Primarily excreted in urine
 238 – 516 umol/L (4.0-8.6 mg/dL) in men
 178 – 351 umol/L (3.0-5.9mg/dL) in women
 Estrogen is uricosuric
 Urinary uric acid
 <750mg per 24 hr
 Useful in assessing the risk of stones
 50% of patients with acute gouty attack will have
normal levels
 Inflammatory cytokines can be uricosuric
 Target of therapy: <6mg/dL
 Diagnosis
38

 Radiography
 Early
in the disease: swelling
 Advanced tophaceous gout:
 Cystic changes, well-defined erosions with sclerotic margins
(often with overhanging bony edges), and soft tissue masses
 Synovial Fluid Aspiration
39
 Synovial Fluid Aspiration
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 Synovial fluid glucose, protein, LDH, lactate or

autoantibodies is NOT recommended because they have
NO diagnostic value
 Normal
 Clear or pale straw color
 Viscous (hyaluronate)
 Non-inflammatory
 Clear, viscous, amber-colored
 WBC <2000/uL, predominantly
mononuclear
 (+) stringing effect
 Inflammatory
 Turbid, yellow, low viscosity
 WBC 2000-50,000/uL, predominantly PMN
 Polarized Microscopy
41

Monosodium Urate Calcium pyrophosphate dihydrate

 Treatment: Acute Attacks
42
 Mainstay: anti-inflammatory
 NSAIDs (if without
complicating comorbids)
 Resolution in 5-8days
 Indomethacin 25-50mg TID
 Naproxen 500mg BID
 Ibuprofen 800mg TID
 Diclofenac 50mg TID
 Celecoxib 800mg then 400mg
after 12h then 400mg BID
 Ice pack
 Rest
 Colchicine (must be used early in
attack)
 0.6mg/tab q8 with subsequent
tapering OR
 1.2mg then 0.6mg after 1hr with
subsequent day dosing
 d/c if with loose
stools/clarithromycin use
 Glucocorticoids
 Prednisone 30-50mg/day then
tapered
 Intraarticular triamcinolone
acetonide 20-40mg
 Intraarticular methylprednisone
25-50mg
 Treatment
43
 Hypouricemic Therapy
 Goal: <300-360 umol/L (5-
6mg/dL)
 When to start?
 Cost-effective after 2 attacks
 BUA >535umol/L (>9mg/dL)
 Px willing to commit to life-long
Tx
 (+) Urate stones
 (+) tophi / chronic GA
 How long?
 Until normouricemic and without
gouty attacks for 6 months
 As long as (+) tophi
 Drugs that are mildly uricosuric:
losartan, fenofibrate,
amlodipine
 Probenecid 250mg BID then up to 3g/d
 Good renal fxn
 Urine UA <600mg/day
(underexcreters)
 Allopurinol 100mg OD AM up to 800mg
 Renal disease (crea >177umol/L)
 Overproducers
 Urate stones
 Febuxostat 40 or 80mg OD
 Allergy to allopurinol, no renal
adjustment needed
 Xanthine oxidase inhibitor
 Pegloticase 8g/IV q2weeks
 Pegylated uricase
 Treatment
44

 Dietary/lifestyle modification:
 Control body weight
 Low-purine diet

 Increase OFI

 Limit ethanol use

 Decrease fructose-containing food and beverages

 Avoidance of diuretics
45 Journal: Update
 European League Against Rheumatism 2016
recommendations on gout management
46

 Systematic Review
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 References
52

- Fauci et al., Harrison’s Principles of Internal Medicine, 19th

edition, 2015
- Richette P, et al. Ann Rheum Dis 2016;0:1–14.
doi:10.1136/annrheumdis-2016-209707
53

Thank you.