[Treatment for gouty arthritis]

Most gouty attacks are controlled with non-steroidal anti-inflammatory drugs (NSAIDs). To reduce side effects, appropriate use of short acting and long acting NSAID is necessary. Colchicine administration is limited to a small amount (0.5-2 mg) in the prodromal stage or within 24 hours of the gouty attack. Steroids are sometimes intra-articular administered to obtain rapid effects. Systemic liposteroid administration has been favorably performed for severe cases of repeated gouty attacks. Uric acid control should not be initiated until after the complete disappearance of the gouty attack. It is important to gradually decrease the urate accumulation and the uric acid level is controlled with a target value near the saturation concentration of urate in the joint fluid (6.0-7.0 mg/dl).

[Metabolic disorder of purine nucleotide in patients with renal disease]

The serum levels of uric acid, hypoxanthine and xanthine tended to increase with the decrease of renal function. This mechanism was thought to be the decreased excretion of these materials from the kidney. More than ninety percent of the patients with renal insufficiency (Ccr < or = 30 ml/min) showed hyperuricemia. In general, the gouty arthritis was reported to be uncommon in the patients with secondary hyperuricemia due to renal insufficiency. However, the frequency of gouty arthritis was reported to be high in the patients with polycystic disease and lead nephropathy. The therapeutic standard for secondary hyperuricemia with renal insufficiency was not established. Allopurinol is the drug of choice for controlling hyperuricemia due to renal insufficiency in many cases. In renal insufficiency, the drug must be used cautiously and in reduced dosage because increased serum concentration of oxipurinol, active metabolite of allopurinol, may induce severe side effect.

A former hockey player with knee and calf pain

A 37-year-old man presented with severe pain in his left knee and calf. He had no other joint pain, fever, chills, or dysuria. He had previously gone to another hospital, where x-rays of the knees and legs reportedly showed inflammation and arthritis. He had been given oxycodone-acetaminophen, but the pain continued.

Crystal-induced arthritis: an overview

The most common crystal-related arthropathies-gout, calcium pyrophosphate dihydrate disease or "pseudogout," and calcific periarthritis/tendinitis-may be appropriately diagnosed and managed by the primary care physician. Definitive diagnosis via synovial tap is recommended, as the clinical picture may not identify some cases. The acute pain and swelling of attacks, regardless of etiology, generally respond to treatment with nonsteroidal anti-inflammatory drugs and local or occasionally systemic corticosteroids. Once a causative crystal has been identified and a diagnosis established, a plan for long-term management and prevention of recurrences may be devised. Thus, uric-acid-lowering therapy may be indicated in a patient who has experienced recurrent attacks of gout, whereas control of serum phosphate levels might be effective in some individuals with hyperphosphatemia and hydroxyapatite-associated periarthritis or arthritis. Crystal deposits in joints can be destructive as well as painful. Treatment, therefore, has two objectives: To relieve the pain of the acute attack, thus restoring normal function, and to prevent the accumulation of crystals that can lead to degenerative disease. Identification and subsequent treatment of preventable or correctable underlying disorders may be one of the most gratifying aspects of managing crystal-induced arthropathies.

Clinics in diagnostic imaging (2). Juvenile gouty arthropathy with associated nephropathy

A 36-year-old Chinese man presented with clinical and biochemical features of renal failure. He has had recurrent attacks of acute gouty arthritis since the age of 15 years. Present radiographic features of extensive chronic tophaceous gout included soft tissue masses, calcification, and typical erosions in the hand and feet. The condition of familial juvenile gouty nephropathy is discussed. Awareness of juvenile-onset gouty arthropathy should lead to early investigation, diagnosis and appropriate management. The complication of associated nephropathy may potentially be prevented.

Postsurgical gout

Although catabolic events are known to precipitate gout, postsurgical gout has rarely been reported. We identified the charts of 302 patients treated over a 10-year period in a university center who carried the diagnosis of gout and who also had a surgical procedure. Fifty-two patients (42 male, 10 female) were found to have had a postsurgical episode of gouty arthritis. Ages ranged from 20 to 82 years (mean 60.1 +/- 2.1). Forty-five patients had a history of gout, 22 of whom were receiving medication and 23 who were not receiving chronic therapy. In seven patients the postsurgical event was their first attack. Attacks occurred 1-17 days (mean 4.2 +/- 0.5 [SE]) after surgical admission. Most attacks were in the lower extremity, but classic podagra was uncommon. Essentially all patients were febrile (100.7 +/- 0.2 degrees F) compared with admission (99.0 +/- 0.1 degree) (P < 0.001). There was a trend toward leukocytosis in the group as a whole, but the relationship of leukocytosis to the gout attack was most clearly seen in patients admitted for noninflammatory conditions (9.4 +/- 0.7 versus 12.8 +/- 0.8 x 1000 WBC/mm3, P < 0.001). Uric acid levels were elevated but did not follow the course of the attack. Most patients underwent a variety of tests and consultative evaluations because of their undiagnosed febrile episode. Once the diagnosis was established, all patients responded quickly to nonsteroidal anti-inflammatory drugs or colchicine. Despite evidence of a significant inflammatory response, no patient proved to have a suppurative focus as the source of their febrile episode.(ABSTRACT TRUNCATED AT 250 WORDS)

[Arthritis urica. Clinical picture, diagnosis and treatment]

Gout is an acute episodic monarthritis or chronic pauci- or polyarticular arthritis. The symptoms of gout are induced by monosodium-urate crystals that are liberated from accumulations in connective tissue structures, primarily cartilage. Deposition of monosodium-urate crystals is caused by hyperuricaemia, which is dealt with in a previous paper. Only a minority of persons with hyperuricaemia develop gout, however. The diagnosis is based on detection of urate crystals in synovial fluid or tophi. Acute gout is treated with antiinflammatory agents, primarily NSAIDs or colchicine. Predisposing diseases and associated conditions such as hypertension, diuretic drugs, overweight and nephropathy should be controlled as well as possible. In patients with recurrent attacks of acute gout or chronic gout, treatment with urate lowering drugs, principally allopurinol, should be given. Treatment with allopurinol should be adjusted according to levels of serum urate and renal function. Serious complications to allopurinol treatment have been described.

Body lead stores and urate excretion in men with chronic renal disease

OBJECTIVE

To determine the relationship of urate excretion to body lead stores in patients with chronic renal disease without previous lead exposure.

METHODS

We compared 40 male subjects in 3 groups, on the basis of their serum creatinine and histories of gout, with serum urate, creatinine clearance, urate clearance, daily urate excretion, fractional urate excretion, and body lead stores. Group 1 consisted of 10 patients with normal serum creatinine levels and no evidence of gout. Group 2 contained 10 men with gout and abnormal serum creatinine levels. Group 3 included 20 subjects with abnormal serum creatinine levels and no evidence of gout. All patients received EDTA mobilization tests and 72 h urine collections. The total amount of lead excreted over 72 h was estimated as the body lead stores. An ANOVA test with Fisher pairwise least significant difference, correlation coefficients, and multiple linear regression test were used to measure any statistical significance among these variables. A p value < 0.05 was considered significant.

RESULTS

Lead stores and serum urate were significantly higher in gouty patients with renal insufficiency than those of other groups, but the urate excretion of gouty patients was not relatively increased. Not only was there a significant correlation between creatinine clearance and urate excretion, but body lead stores also appeared to be negatively related to urate excretion in our patients, even though body lead stores in these subjects were within the normal range.

CONCLUSION

Our findings suggest that lead may play a role in gouty patients with impaired renal function and chronic low level environmental lead exposure may subtly affect urate excretion in patients with chronic renal disease.

Gouty arthritis in end-stage renal disease: clinical course and rarity of new cases

We studied 201 end-stage renal disease (ESRD) patients sustained on maintenance hemodialysis (MD) (n = 164) and chronic ambulatory peritoneal dialysis (CAPD) (n = 37) to determine (1) the frequency of acute attacks of gouty arthritis (GA) in those ESRD patients who had GA before dialytic therapy, and (2) the incidence of new-onset GA in hyperuricemic long-term (> 12 years) ESRD patients on MD. The 2-month mean of predialysis serum uric acid levels was calculated for each subject and the prevalence of hyperuricemia ascertained. There were 25 patients on MD for more than 12 years, and this group was evaluated and analyzed separately from those patients on dialytic therapy for less than 12 years; the mean of each of their predialysis uric acid values was calculated for each subject for at least 60% of the time they have been on dialysis. Patients who had GA before or after initiation of dialytic therapy were identified, and the frequency of acute attacks of GA determined. The presence of treated hypertension in each subject was noted. Thirteen of 201 patients had clinically active GA before commencing dialytic therapy, and each recalled a minimum of two painful attacks of GA per year before the initiation of ESRD therapy. Mean duration of ESRD for these 13 patients was 25 +/- 3.8 months; painful attacks of GA have not recurred in nine patients (70%), and the frequency of attacks declined by 50% in the remaining four patients (30%), despite persistent hyperuricemia in all 13.(ABSTRACT TRUNCATED AT 250 WORDS)

Hyperuricemia and urate nephropathy in urate oxidase-deficient mice

Urate oxidase, or uricase (EC 1.7.3.3), is a purine metabolic enzyme that catalyzes the conversion of uric acid to allantoin in most mammals except humans and certain other primates. The loss of urate oxidase in the human during primate evolution predisposes man to hyperuricemia, a metabolic disturbance that can lead to gouty arthritis and renal stones. To create a mouse model for hyperuricemia and gout, and to address the question of whether urate oxidase is essential in lower mammalian species, we have disrupted the urate oxidase gene in the mouse by homologous recombination in embryonic stem cells. Unlike the human situation, urate oxidase deficiency in mice causes pronounced hyperuricemia and urate nephropathy. More than half of the mutant mice died before 4 weeks of age, indicating that urate oxidase is essential in mice. These mutant mice may also serve as animal models for hyperuricemia and its related nephropathy in humans.

[Physiopathology and treatment of acute gouty arthritis]

Severe gouty arthritis is a clinical expression of a very intense inflammatory process. The initial pathogenic event which sets off the chain process is the intraarticular deposit of monosodium urate crystals. However, urate crystals do not always promote an inflammatory process (e.g., dormant tophus), and only a minority of patients with hyperuricemia develop gout. The therapeutic bases for gout should be based on the knowledge surrounding the physiopathology of the inflammatory process. In this study, we present the physiopathology of severe gouty arthritis in order to improve understanding of its treatment.

Carpal tunnel release complicated by acute gout

We report a patient who suffered an acute attack of gout in the wrist after surgical release for carpal tunnel syndrome. The postoperative management of this patient and a brief review of this complication of carpal tunnel release are discussed.

Systemic complications of cyanosis in adults with congenital heart disease. Hematologic derangements, renal function, and urate metabolism

The regulation of red cell mass, the hemostatic derangements, the structure and function of the kidneys and the determinants of plasma urate levels are important concerns in the clinical management of adults with cyanotic congenital heart disease. Because these topics are interrelated, they are discussed together in terms of pathogenesis, clinical expression, and management.

[Pseudopodagra caused by hydroxyapatite. Report of 3 cases]

Calcium hydroxyapatite crystals deposit in periarticular soft tissues usually translates itself clinically through pain and mobility limitation of affected joint. Compromise of small joints in feet is infrequent, less than 1% of all cases. Recently pseudopodagra crises have been described due to the deposit of this material in soft tissues adjacent to metatarsal or phalangeal first joint. Its clinical expression is practically undistinguishable from gout crises. Three new cases of pseudopodagra due to hidroxyamatite are presented and some considerations are made concerning this clinical entity and its differential diagnosis in relation to gout.

[Rheumatologic manifestations in heart transplant recipients. A cross-sectional study of 365 patients]

Rheumatological complications are sometimes disabling in heart transplant recipients and may negate the good results obtained with transplantation. The objective of this study was to evaluate the incidence of these complications. 365 consecutive heart transplant recipients (292 males and 73 females) were systematically interviewed and examined according to a standardized protocol. The mean age of the patients was 45.9 +/- 12.0 years (range: 11-68). The mean duration from transplantation to time of the study was 35.8 +/- 25.6 months (range: 1-115). The rheumatological disorders most frequently encountered were: gout, osteoporosis, osteonecrosis and myalgias. Early-onset polyarticular gout was diagnosed in 63/365 patients (17.3%). This diagnosis was significantly associated with patient's age, time since transplant, male sex, serum uric acid, serum creatinine, diuretics intake and inversely associated with the serum cyclosporin levels. Hyperuricemia was observed in 75.9% of transplant recipients with a mean of 507.5 +/- 132.5 mumol/l (range: 97-965). An osteoporotic fracture was present in 18/365 patients (4.9%) and was significantly associated with the patient's age, but not with the dose of corticosteroids. Osteonecrosis was detected in 10/365 patients (2.7%), always affected the hip, and was significantly associated with the patient's age, but not with the high doses of steroids. Myalgias were reported by 14/365 patients (3.8%). Laboratory, electromyographic and histological analysis were negative. Rheumatological complications are frequent in heart transplant recipients and justify preventive and therapeutic management.

[Crystal-induced arthropathies]

The formation and deposition of crystals in articular tissues increases with growing age. As a consequence crystal-induced or crystal-associated arthritides or arthropathies can be observed particularly in the elderly where these disorders comprise a considerable part of inflammatory joint diseases. Gout, induced by monosodiumrate crystals mostly presents as acute monarthritis, less frequently as a chronic polyarthritis. Calciumpyrophosphate deposition may induce acute pseudo-gout, rheumatoid-arthritis-like (pseudo-rheumatoid) arthritis and a variety of other clinical syndromes. Basic calciumphosphate crystals may be associated with acute and chronic recurrent or destructive arthropathies. The detection of crystals in joint fluids by polarized microscopy as well as typical X-ray-findings allow to make a diagnosis in the context of characteristic clinical features. In addition to the antiinflammatory treatment it is important to detect and treat underlying metabolic disorders.

Monoarticular gout following trauma: MR appearance

We report a case of gout with monoarticular tophaceous involvement of the proximal interphalangeal joint of the middle finger, emphasizing MR findings. To the best of our knowledge, the MR appearance of gout is not commonly known.

A study of uric acid metabolism and gouty arthritis in patients with polycystic kidney

It has been found that polycystic kidney (ADPKD) is often associated with gout. On the other hand, there are reports describing that the hyperuricemia (HU) seen in ADPKD corresponds to a reduction in renal function. We investigated the uric acid metabolism in 44 patients with ADPKD (age, 50 +/- 12.8 years; CCR, 50.5 +/- 41.1 ml/min) at our hospital. From among these 44 patients, 14 with a CCR of 80 ml/min were selected. Their data for uric acid metabolism were compared against those from the previous year's studies on various disease types (114 normal subjects, 70 with membranous nephropathy, 175 with IgA nephritis, 122 with gout, 137 with asymptomatic hyperuricemia, and 42 with diabetes mellitus). Among the 44 patients with ADPKD, the serum uric acid (SUA) was 7.7 +/- 1.9 mg/dl and HU affected 28 (63.6%). The incidence of gouty arthritis was also high (6 patients, 13.6%), revealing a positive correlation between SUA and CCR. Compared with membranous nephropathy and IgA nephritis, ADPKD exhibited an accentuated increase in SUA associated with a reduction in CCR. It is believed that this represents a factor for a high incidence of complications of hyperuricemia and gouty arthritis in ADPKD in contrast to other diseases. However, no increase in the production of uric acid was noted in ADPKD.