DOCSLIB.ORG

Hemarthrosis

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Hemarthrosis Case Report DOI: 10.5455/amaj.2016.02.012 Hemarthrosis: Concurrent acute presentation of pyrophosphate dehydrate and uric acid crystals in an elderly patient with a history of rheumatoid ar- thritis diagnosed with septic arthritis Feredun Azari, BS-MD Rauf Shahbazov, MD, PhD* Concomitant septic arthritis in the presence of crystalline disease is a rare presen- tation of acute hemarthrosis and knee pain. Literature review showed that co-occur- Department of Surgery, rence of these entities is an infrequent phenomenon but it needs to be acknowledged University of Virginia, that these studies are few in number and were done on small patient population. This Charlottesville, Virginia, USA case challenges the notion that presence of crystals in the synovial fluid rules out sep- tic arthritis even in the setting of low synovial WBC count. Additionally, the presence Correspondence: of pseudogout in patients suffering from gout is a rare entity as well. These findings Rauf Shahbazov MD, PhD, Organ Trans- in literature are described in case reports dispersed over the past three decades. We plantation Unit, University of Virginia present a case where concurrent treatment of gout, pseudogout, and septic arthritis Medical Center, Charlottesville, Virginia, in a patient who presented with acute hemarhtrosis. USA email: [email protected] Keywords: gout, pseudogout, rheumatoid arthritis, infection Phone: 434-872-1373 Introduction tions [1]. Vigilance is needed to have a low ge related crystal induced arthropathies threshold for ruling out septic arthritis in Aare a common phenomenon presenting this patient population. This is usually done to the primary care office or the emergency via synovial fluid analysis but as demon- department [1,2]. The two most common strated in this case report, it does not pathologies that are encountered are pseud- necessarily provide a clear answer to the ogout (Calcium Pyrophosphate Deposition problem, especially in patients with multi- Disease - CPPD) and gout. Gout classically ple comorbidities. Even if the diagnosis is presents with podagra and/or severe pain not clear, appropriate antibiotic therapy is involving the joints of the upper digits. necessary if suspicion remains. Physicians With poor management of the disease, it should use their clinical judgment based can progress to multi-joint involvement and on patient presentation in order to arrive subcutaneous depositions known as tophi. at proper diagnosis and initiate appropriate CPPD on the other hand involves the knee care plan. joints at the onset with later progression to other areas. The management of these en- Case Presentation tities include acute pain control, chronic 62-year-old Caucasian male with a his- suppressive therapy, and avoiding dietary tory of gout (currently on allopurinol and and/or social triggers. The concurrent pre- colchicine), rheumatoid arthritis (on chron- sentation of these diseases can affect chronic ic methotrexate suppression therapy), mul- management and lead to increased patient tiple arthroplasties in the span of last 30 discomfort. However, the co-occurrence of years due to complications of osteoarthritis these entities are rare [2,3]. presented to the ED with acute onset right Patients suffering from rheumatoid ar- knee pain and swelling status post exiting thritis usually require long term steroid and his vehicle. He did not endorse popping possible immunosuppressive therapy. This sensation or pain at that time but reported leads to increased susceptibility towards life worsening pain within four to five hours threatening or limb endangering infec- with subjective fevers and chills. Patient was www.amaj.az AMAJ Azari et al. 2016; 2: 38-40 Acute presentation of CPPD and uric acid crystals 39 in moderate distress due to pain in the emergency department for acute gout flare, 1.2 mg of colchicine initially then reduced and had limited mobility in his right leg as well. Patient was to 0.6 mg daily. Broad spectrum antibiotic coverage was contin- hemodynamically stable except for elevated blood pressure of ued for the next three days and was switched to oral treatment 190/95 and low grade fever of 38.00 C, which at the time was regimen for fourteen days at the time of discharge. Patient noted attributed to severity of the pain. significant relief two days later and was able to ambulate. Physical exam was remarkable for tenderness to palpation of the affected knee, significant swelling of the right knee with Discussion negative anterior or posterior drawer test. Initial labs showed Simultaneous presentations of pseudogout, gout with con- elevated white blood cell count of 11,000 causing concern for comitant septic arthritis have been described in handful of case possible septic arthritis, which led to the ED staff to perform reports in patients suffering from chronic arthritic disease [2,3]. arthrocentesis of the affected joint. Forty milliliters of serosan- There have been handful reports describing these diseases oc- guineous fluid was extracted. Fluid profile showed 40,149 WBC curring together in the last three decades. According to Stock- and crystals. Patient noted partial relief from pain. Of note, co- man et al, 5.8% of patients (8/138) who suffered from gout had agulation studies were unremarkable but there was a mild ele- concomitant pseudogout [10]. Imaging findings show concom- vation in CRP. Broad-spectrum antibiotics were initiated due itant erosions and chondrocalcinosis associated with both types to equivocal fluid analysis and patient presentation. Within the of crystalline disease, which is rarely seen on conventional im- next two hours, return of erythema and swelling was noted on aging (Figure 2). the affected knee. Hydromorphone PCA was initiated for the Diagnosis in this patient was relatively straightforward since patient. MRI and x-ray was unchanged from previous studies both of the crystalline diseases were identified under synovial done 5 years ago, which showed osteopenia, chondrocalcinosis fluid analysis using careful polarized light microscopy. Further- and severe cartilage loss on the patella (Figure 1). more, it is important to rule out serious pathology such aseptic Following day, another arthrocentesis was performed by or- arthritis by obtaining synovial fluid culture before starting treat- thopedic surgery. Fluid showed serosanguineous profile as well. ment [6]. Our patient has a history of RA, which according to Analysis showed 17,420 WBC, 17% hematocrit, monosodium some studies indicate 15 times increased risk of septic arthritis, urate, and pyrophosphate dehydrate crystals. No bacterial, fun- especially given the current disease-modifying anti-rheumatic gal elements, or AFB were seen in the initial culture analysis but drug (DMARD) therapy [1,4]. Given the patient had an elevat- cultures three days later showed S.aureus that was resistant to ed white count with mono-articular presentation, septic arthri- methicillin. Patient was started on naproxen 500 mg twice daily tis was higher on the differential versus crystal deposition dis- Figure 1. Figure 2. Knee X-ray performed in the emergency department shows Rare radiological coexistence of CPPD and gout in a patient chondrocalcinosis (arrow) suggestive of severe long stand- with poor management of underlying disease. Classic ing pseudogout as well as severe cartilage loss consistent punched-out lesions (black arrow) are seen with inter- with patient’s history. spersed joint space chondrocalcinosis (white arrow). www.amaj.az Azari et al. AMAJ 40 Acute presentation of CPPD and uric acid crystals 2016; 2: 38-40 ease. Nevertheless, synovial fluid analysis revealed the causative References bacterial organism and the treatment was initiated accordingly. 1. Al-Ahaideb A. Septic arthritis in patients with rheuma- This patient had extensive history of osteoarthritis with sur- toid arthritis. J Orthop Surg. 2008 Jul 29;3:33. gical interventions dating back to his early 20’s as well as history 2. Alappatt C, Clayburne G, Schumacher R. Concomitant of RA. Thus it would not be unusual for this patient to present polyarticular septic and gouty arthritis. The Journal of with hemarthrosis after a minor trauma causing ACL or PCL rheumatology. 2006;33(8):1707–1708. tear [9]. This was ruled out from MRI even though it was of lim- 3. De Bari C, Lapadula G, Cantatore FP. Coexisting psoriat- ited value due to patient’s inability to fully comply due to pain. ic arthritis, gout, and chondrocalcinosis. Scand J Rheu- Hemarthrosis due to RA is not unusual, and was considered here matol. 1998;27(4):306–309. as it was observed that a patient had a significant increase in 4. Galloway JB, Hyrich KL, Mercer LK, Dixon WG, Us- synovial WBC’s [9]. Conversely, RA induced flare usually have tianowski AP, Helbert M, Watson KD, Lunt M, Symmons WBC count of above 50,000 with significantly elevated CRP and DPM. Risk of septic arthritis in patients with rheuma- ESR. This patient’s CRP level was not impressive at the time of toid arthritis and the effect of anti-TNF therapy: results presentation and marker levels decreased as expected with the from the British Society for Rheumatology Biologics initiation of therapy. It is also unusual to have an acute RA flare Register. Ann Rheum Dis. 2011 Oct 1;70(10):1810–1814. from minor trauma in a patient who has been compliant with 5. Margaretten ME, Kohlwes J, Moore D, Bent S. therapy. Does this adult patient have septic arthritis? Jama. Spontaneous hemarthrosis of the knee should also raise sus- 2007;297(13):1478–1488. picion for possible hemophilia but negative past history, fami- 6. Shah K, Spear J, Nathanson LA, McCauley J, Edlow JA. ly history, age of presentation and normal coagulation studies Does the presence of crystal arthritis rule out septic ar- makes this unlikely at this stage. Regardless of etiology, proper thritis? J Emerg Med. 2007 Jan;32(1):23–26. acquisition and interpretation of synovial fluid is paramount 7. Tejera B, Riveros A, Martínez-Morillo M, Caíellas J. Sep- for proper diagnosis and treatment of acute monoarthritis tic Arthritis Associated to Gout and Pseudogout: The with presumed concomitant septic arthritis [5,6,10].
Load more

Recommended publications
  • Updated Treatment for Calcium Pyrophosphate Deposition Disease: an Insight
    Open Access Review Article DOI: 10.7759/cureus.3840 Updated Treatment for Calcium Pyrophosphate Deposition Disease: An Insight Shumaila M. Iqbal 1 , Sana Qadir 2 , Hafiz M. Aslam 3 , Madiha A. Qadir 4 1. Internal Medicine, University at Buffalo / Sisters of Charity Hospital, Buffalo, USA 2. Internal Medicine, S & A Pediatrics, Parsippany, USA 3. Internal Medicine, Seton Hall University / Hackensack Meridian School of Medicine, Trenton, USA 4. Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK Corresponding author: Shumaila M. Iqbal, [email protected] Abstract Calcium pyrophosphate disease (CPPD) is caused by the deposition of calcium pyrophosphate (CPP) crystals in the joint tissues, particularly fibrocartilage and hyaline cartilage. CPP crystals trigger inflammation, causing local articular tissue damage. Our review article below covers different aspects of CPPD. It discusses how CPPD can manifest as different kinds of arthritis, which may be symptomatic or asymptomatic. The metabolic and endocrine disease associations and routine investigations used in the diagnostic workup are briefly reviewed. Conventional and newer therapies for the treatment of CPPD are outlined. Overall, this extensive review would provide an updated insight to clinicians for evidence-based treatment of CPPD. Categories: Rheumatology Keywords: calcium pyrophosphate deposition disease, calcium pyrophosphate crystal, arthritis, colchicine, immunomodulants, nsaid Introduction And Background Calcium pyrophosphate deposition disease (CPPD) is caused by the deposition of calcium pyrophosphate (CCP) crystals in the articular cartilage, resulting in inflammation and degenerative changes in the affected joint. CPPD is a collective term that comprises all the various forms of CPP crystal-induced arthropathies. The acute arthritis attack caused by CPP crystals deposition triggers the same inflammatory reaction in the joint tissues as do the monosodium urate crystals in gout patients.
    [Show full text]
  • Juvenile Spondyloarthropathies: Inflammation in Disguise
    PP.qxd:06/15-2 Ped Perspectives 7/25/08 10:49 AM Page 2 APEDIATRIC Volume 17, Number 2 2008 Juvenile Spondyloarthropathieserspective Inflammation in DisguiseP by Evren Akin, M.D. The spondyloarthropathies are a group of inflammatory conditions that involve the spine (sacroiliitis and spondylitis), joints (asymmetric peripheral Case Study arthropathy) and tendons (enthesopathy). The clinical subsets of spondyloarthropathies constitute a wide spectrum, including: • Ankylosing spondylitis What does spondyloarthropathy • Psoriatic arthritis look like in a child? • Reactive arthritis • Inflammatory bowel disease associated with arthritis A 12-year-old boy is actively involved in sports. • Undifferentiated sacroiliitis When his right toe starts to hurt, overuse injury is Depending on the subtype, extra-articular manifestations might involve the eyes, thought to be the cause. The right toe eventually skin, lungs, gastrointestinal tract and heart. The most commonly accepted swells up, and he is referred to a rheumatologist to classification criteria for spondyloarthropathies are from the European evaluate for possible gout. Over the next few Spondyloarthropathy Study Group (ESSG). See Table 1. weeks, his right knee begins hurting as well. At the rheumatologist’s office, arthritis of the right second The juvenile spondyloarthropathies — which are the focus of this article — toe and the right knee is noted. Family history is might be defined as any spondyloarthropathy subtype that is diagnosed before remarkable for back stiffness in the father, which is age 17. It should be noted, however, that adult and juvenile spondyloar- reported as “due to sports participation.” thropathies exist on a continuum. In other words, many children diagnosed with a type of juvenile spondyloarthropathy will eventually fulfill criteria for Antinuclear antibody (ANA) and rheumatoid factor adult spondyloarthropathy.
    [Show full text]
  • Uncontrolled Gout Fact Sheet
    What is gout? Gout is a type of painful, inflammatory arthritis caused by too much uric acid in the blood, either because the body makes more than it should, or the kidneys do not remove as much as they should. An estimated So, what is ⅔ produced by 9.2 million the body Americans live with gout Some suffer from uncontrolled a chronic and uric debilitating form of the acid condition – known as gout? ⅓ uncontrolled gout. dietary intake Uncontrolled gout occurs when a person In many cases, gout can be managed with experiences ongoing symptoms and high uric standard therapies and lifestyle changes. acid levels, even while taking gout medication. But what about when it’s not? approximately Frequent visits to the 1993 number of 255,000 hospital may mean gout 8,454 hospitalizations 2011 is uncontrolled. hospitalizations for 20,949 gout from 1993 – 2011 Symptoms of uncontrolled gout include: MULTIPLE GOUT FLARES TOPHI ONGOING PAIN uric acid crystal deposits, two or more flares, which look like lumps sometimes called gout under the skin, that do not attacks, per year go away when a flare stops that continues between flares To avoid gout and other problems, uric acid levels should be 6.0 mg/dL or below. If you have these signs and symptoms your uric acid level may need to be at or below 5 mg per dL. Take a Step in Controlling Gout 1 2 3 Learn more GoutRevealed.com See a gout specialist, most Talk about your gout symptoms, Visit the link above to hear from other commonly a rheumatologist.
    [Show full text]
  • Arthritis (Overview)
    ARTHRITIS Having arthritis can significantly affect your comfort & ability to walk and move with confidence. This is because it affects your joints, which are responsible for keeping you steady and moving efficiently. Your symptoms and causes will depend on the type of arthritis that you have. At Masterton Foot Clinic, our podiatrists work closely with patients with four types of arthritis. OSTEOARTHRITIS Osteoarthritis is the wear and tear arthritis that develops slowly over time as the cartilage that covers your bone ends wears down. The cause is largely from natural use over many years, though injuries, alignment issues within the joint and other diseases may result in it developing at a faster rate. We work with patients that want to feel more comfortable on their feet, despite having arthritis in their hip, knee, ankle and foot joints. RHEUMATOID ARTHRITIS Rheumatoid arthritis is an autoimmune disease that affects the joints. It occurs when your body’s immune system attacks the joints and causes damage, inflammation and pain. If the effects of rheumatoid arthritis remain uncontrolled, it can cause permanent changes in the appearance of the joints, especially at the feet and hands. We work with patients to help them manage the discomfort associated with rheumatoid arthritis, offloading prominent and painful areas that have developed due to changes in the joints. GOUT Gout is an inflammatory arthritis that results from a high concentration of uric acid in the blood. It is associated with a high intake of purine-containing foods like red meats, shellfish and red wine, hence it was previously referred to as the rich man’s disease.
    [Show full text]
  • ACR Appropriateness Criteria® Chronic Knee Pain
    Revised 2018 American College of Radiology ACR Appropriateness Criteria® Chronic Knee Pain Variant 1: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial imaging. Procedure Appropriateness Category Relative Radiation Level Radiography knee Usually Appropriate ☢ Image-guided aspiration knee Usually Not Appropriate Varies CT arthrography knee Usually Not Appropriate ☢ CT knee with IV contrast Usually Not Appropriate ☢ CT knee without and with IV contrast Usually Not Appropriate ☢ CT knee without IV contrast Usually Not Appropriate ☢ MR arthrography knee Usually Not Appropriate O MRI knee without and with IV contrast Usually Not Appropriate O MRI knee without IV contrast Usually Not Appropriate O Bone scan knee Usually Not Appropriate ☢☢☢ US knee Usually Not Appropriate O Radiography hip ipsilateral Usually Not Appropriate ☢☢☢ Variant 2: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee radiograph negative or demonstrates joint effusion. Next imaging procedure. Procedure Appropriateness Category Relative Radiation Level MRI knee without IV contrast Usually Appropriate O Image-guided aspiration knee May Be Appropriate Varies CT arthrography knee May Be Appropriate ☢ CT knee without IV contrast May Be Appropriate ☢ US knee May Be Appropriate (Disagreement) O Radiography hip ipsilateral May Be Appropriate ☢☢☢ Radiography lumbar spine May Be Appropriate ☢☢☢ MR arthrography knee May Be Appropriate O MRI knee without and with IV contrast Usually Not Appropriate O CT knee with IV contrast Usually Not Appropriate ☢ CT knee without and with IV contrast Usually Not Appropriate ☢ Bone scan knee Usually Not Appropriate ☢☢☢ ACR Appropriateness Criteria® 1 Chronic Knee Pain Variant 3: Adult or child greater than or equal to 5 years of age.
    [Show full text]
  • Gout and Monoarthritis
    Gout and Monoarthritis Acute monoarthritis has numerous causes, but most commonly is related to crystals (gout and pseudogout), trauma and infection. Early diagnosis is critical in order to identify and treat septic arthritis, which can lead to rapid joint destruction. Joint aspiration is the gold standard method of diagnosis. For many reasons, managing gout, both acutely and as a chronic disease, is challenging. Registrars need to develop a systematic approach to assessing monoarthritis, and be familiar with the management of gout and other crystal arthropathies. TEACHING AND • Aetiology of acute monoarthritis LEARNING AREAS • Risk factors for gout and septic arthritis • Clinical features and stages of gout • Investigation of monoarthritis (bloods, imaging, synovial fluid analysis) • Joint aspiration techniques • Interpretation of synovial fluid analysis • Management of hyperuricaemia and gout (acute and chronic), including indications and targets for urate-lowering therapy • Adverse effects of medications for gout, including Steven-Johnson syndrome • Indications and pathway for referral PRE- SESSION • Read the AAFP article - Diagnosing Acute Monoarthritis in Adults: A Practical Approach for the Family ACTIVITIES Physician TEACHING TIPS • Monoarthritis may be the first symptom of an inflammatory polyarthritis AND TRAPS • Consider gonococcal infection in younger patients with monoarthritis • Fever may be absent in patients with septic arthritis, and present in gout • Fleeting monoarthritis suggests gonococcal arthritis or rheumatic fever
    [Show full text]
  • Imaging in Gout and Other Crystal-Related Arthropathies 625
    ImaginginGoutand Other Crystal-Related Arthropathies a, b Patrick Omoumi, MD, MSc, PhD *, Pascal Zufferey, MD , c b Jacques Malghem, MD , Alexander So, FRCP, PhD KEYWORDS Gout Crystal arthropathy Calcification Imaging Radiography Ultrasound Dual-energy CT MRI KEY POINTS Crystal deposits in and around the joints are common and most often encountered as inci- dental imaging findings in asymptomatic patients. In the chronic setting, imaging features of crystal arthropathies are usually characteristic and allow the differentiation of the type of crystal arthropathy, whereas in the acute phase and in early stages, imaging signs are often nonspecific, and the final diagnosis still relies on the analysis of synovial fluid. Radiography remains the primary imaging tool in the workup of these conditions; ultra- sound has been playing an increasing role for superficially located crystal-induced ar- thropathies, and computerized tomography (CT) is a nice complement to radiography for deeper sites. When performed in the acute stage, MRI may show severe inflammatory changes that could be misleading; correlation to radiographs or CT should help to distinguish crystal arthropathies from infectious or tumoral conditions. Dual-energy CT is a promising tool for the characterization of crystal arthropathies, partic- ularly gout as it permits a quantitative assessment of deposits, and may help in the follow-up of patients. INTRODUCTION The deposition of microcrystals within and around the joint is a common phenomenon. Intra-articular microcrystals
    [Show full text]
  • 19120 Arthritis Aus Gout Booklet
    Taking control of your Gout A practical guide to treatments, services and lifestyle choices How can this booklet help you This booklet is designed for people who have gout. It will help you understand your • make healthy choices for your condition so that you can better general health and wellbeing manage your symptoms and continue • find support and additional to lead an active and healthy life. information to cope with the This booklet offers information and impact of gout. practical advice to help you: The information inside is based • understand what gout is and on the latest research and what it means for you recommendations, and has been reviewed by Australian experts in the • understand how medicines can field of arthritis to make sure it is help treat gout attacks and current and relevant to your needs. prevent future attacks So go ahead — take control of • work with your healthcare team your gout! to manage the disease in the short and long term © Copyright Arthritis Australia 2014 Supported by: AstraZeneca Pty Limited ABN 54 009 682 311 Alma Road, North Ryde NSW 2113 2 Taking control of your Gout Contents Understanding gout 4 Treating gout 10 Diet and lifestyle 16 Who can help? 21 Working with your GP 22 Seeing a rheumatologist 23 Other health professionals 24 Seeking support 26 Glossary of terms 28 Useful resources 29 Medical and consumer consultants Tanya deKroo, Information Resources Coordinator, Arthritis Australia Wendy Favorito, Arthritis Australia Consumer Representative and Board Member Assoc Prof Neil McGill, Rheumatologist Assoc Prof Julian McNeil, Rheumatologist and Chair of Australian Rheumatology Association’s Therapeutics Committee Assoc Prof Peter Youssef, Rheumatologist and Chair of Arthritis Australia’s Scientific Advisory Committee Arthritis Australia 3 Understanding gout What is gout? the main reason for more than Gout is an extremely painful form nine out of ten people with gout).
    [Show full text]
  • 21362 Arthritis Australia a to Z List
    ARTHRITISINFORMATION SHEET Here is the A to Z of arthritis! A D Goodpasture’s syndrome Achilles tendonitis Degenerative joint disease Gout Achondroplasia Dermatomyositis Granulomatous arteritis Acromegalic arthropathy Diabetic finger sclerosis Adhesive capsulitis Diffuse idiopathic skeletal H Adult onset Still’s disease hyperostosis (DISH) Hemarthrosis Ankylosing spondylitis Discitis Hemochromatosis Anserine bursitis Discoid lupus erythematosus Henoch-Schonlein purpura Avascular necrosis Drug-induced lupus Hepatitis B surface antigen disease Duchenne’s muscular dystrophy Hip dysplasia B Dupuytren’s contracture Hurler syndrome Behcet’s syndrome Hypermobility syndrome Bicipital tendonitis E Hypersensitivity vasculitis Blount’s disease Ehlers-Danlos syndrome Hypertrophic osteoarthropathy Brucellar spondylitis Enteropathic arthritis Bursitis Epicondylitis I Erosive inflammatory osteoarthritis Immune complex disease C Exercise-induced compartment Impingement syndrome Calcaneal bursitis syndrome Calcium pyrophosphate dehydrate J (CPPD) F Jaccoud’s arthropathy Crystal deposition disease Fabry’s disease Juvenile ankylosing spondylitis Caplan’s syndrome Familial Mediterranean fever Juvenile dermatomyositis Carpal tunnel syndrome Farber’s lipogranulomatosis Juvenile rheumatoid arthritis Chondrocalcinosis Felty’s syndrome Chondromalacia patellae Fibromyalgia K Chronic synovitis Fifth’s disease Kawasaki disease Chronic recurrent multifocal Flat feet Kienbock’s disease osteomyelitis Foreign body synovitis Churg-Strauss syndrome Freiberg’s disease
    [Show full text]
  • CONCOMITANT GOUT and RHEUMATOID ARTHRITIS - a CASE Presented with Multiple Nodular Swellings on REPORT Feet, Hands, Wrists and Elbows
    349 350 INDIAN JOURNAL OF MEDICAL SCIENCES CASE REPORT consulted various practitioners and took allopathic and indigenous medications but to no relief. Two months prior to admission he CONCOMITANT GOUT AND RHEUMATOID ARTHRITIS - A CASE presented with multiple nodular swellings on REPORT feet, hands, wrists and elbows. Patient’s past medical history is significant for hypertension, POOJA KHOSLA*, ATUL GOGIA**, P. K. AGARWAL***, AMIT PAHUJA**, SUNIL JAIN***, K. K. SAXENA# diabetes mellitus, chronic ethanolism and renal stones for which he underwent left nephrectomy about 25 years ago. Family Abstract history is non-contributory. Figure 1: Multiple nodules present on metatarsal joints of both feet (Gouty Tophi) We report a case of definite rheumatoid arthritis and co-existing gout. Although gout On examination multiple nodules were present and rheumatoid arthritis are relatively common entities individually, the co-existence on metatarsal joints of both feet, Achilles of these two conditions is rare. tendon bilaterally, left prepatellar bursa, bilateral metacarpophalangeal joint, right KEY WORDS: Gout, Rheumatoid Arthritis olecranon process. There was swelling and tenderness of PIP and MCP joints of both feet. (Figure 1) Laboratory data revealed INTRODUCTION metatarsophalangeal joint. He had hemoglobin - 8.9gm/dl, ESR 124 mm at the asymmetrical joint pains and swelling at end of first hour, leucocyte count 7400/cmm Gout and rheumatoid arthritis rarely co-exist in irregular intervals with exacerbations and with normal differential count. Random blood the same patient. As separate disease entities remissions. The symptoms subsided in sugar was 139 mg/dl, Creatinine- 1.6 mg/dl; they are relatively common. Rheumatoid between but there was no period when patient serum uric acid level was 10.9 mg/dl.
    [Show full text]
  • Psoriasis, Psoriatic Arthritis and Secondary Gout – 3 Case Reports
    https://doi.org/10.5272/jimab.2018242.1972 Journal of IMAB Journal of IMAB - Annual Proceeding (Scientific Papers). 2018 Apr-Jun;24(2) ISSN: 1312-773X https://www.journal-imab-bg.org Case report PSORIASIS, PSORIATIC ARTHRITIS AND SECONDARY GOUT – 3 CASE REPORTS Mina I. Ivanova, Rositsa Karalilova, Zguro Batalov. Departement of Rheumatology, Faculty of Medicine, UMHAT Kaspela, Medical University - Plovdiv, Bulgaria. ABSTRACT: cells in the skin (Langerhans cells) migrate to the regional Background: One of the most common complica- lymph nodes, where interacts with T-lymphocytes. This tions in psoriasis is the development of secondary gout that provokes the immune response leading to the activation often remains undiagnosed for many years. In some cases, of T cells and release of cytokines. The local effects of the clinical symptoms of gout precede the manifestation cytokines lead to a cell-mediated immune response. In pso- of cutaneous psoriasis, leading to progression of the dis- riasis skin lesions are results of hyperplasia of the epider- ease and early onset of complications. According to the mis, which leads to enhanced cell reproduction, world data, there is a strong correlation between psoriasis hyperproliferation and at the same time shortening vulgaris and psoriatic arthritis on the one hand and gout keratinocytes’ life. This leads to increased production of on the other ranging from 3 to 40%. In Bulgaria, there are uric acid, as it enhances the exchange of nucleic acids. no studies observing the frequency of secondary gout in Psoriatic arthritis (PsA) occurs in 0.05 to 0.25% from psoriatic patients. the general population.
    [Show full text]
  • The Patient's Guide to Treating and Managing Gout
    Raising the Voice of Patients THE PATIENT’S GUIDE TO TREATING AND MANAGING GOUT First Edition ©2018 GLOBAL HEALTHY LIVING FOUNDATION, INC. Table of Contents 2 PART ONE Introduction 3 PART TWO Patient Charter 6 PART THREE Treatment Guidelines 7 PART FOUR Gout Overview 11 PART FIVE Monitoring 12 PART SIX Treatments Treatments for acute gout flares Colchicine (Colcrys®, Mitigare®) NSAIDS Corticosteroids Corticotropin or Adrenocorticotrophic Hormone (Acthar®, H.P. Acthar Gel®) Xanthine Oxidase Inhibitors Allopurinol (Aloprim®, Lopurim®, Zyloprim®) Febuxostat (Uloric®) Uricosoric Medications Probenecid (Benemid®, Probalan®) Lesinurad (Zurampic®, Duzallo®) Uricase Medications Pegloticase (Krystexxa®) Off-Label Gout Treatments: Anakinra and Canakinumab Surgery 29 PART SEVEN Self Management 35 PART EIGHT Affording Your Treatments 37 PART NINE Make Your Voice Heard 41 PART TEN Conclusion 42 ABOUT THE EDITORS 43 GLOSSARY 44 WORKS REFERENCED THE PATIENT’S GUIDE TO TREATING AND MANAGING GOUT | 1 PART ONE Welcome Welcome to the first edition of CreakyJoints’ patient guide for living with and managing gout. This original guide offers comprehensive, easy-to-understand information on gout and its treatment: what causes gout, how it can affect your body in different ways and progress, how it’s treated and the steps you can take on your own to prevent flares and manage your symptoms. CreakyJoints is a non-profit patient advocacy organization that empowers patients like you to raise your voice with key decision-makers you’ll encounter while living with gout. This guide is the first of its kind, and it has been developed by leading experts, including doctors who specialize in gout management, other healthcare providers and patients like you.
    [Show full text]