Chapter VI - Bone Pathology

Arthritis & Gout

Gout

Gout is a form of arthritis caused by the accumulation of uric acid crystals in joints. It is an intensely painful disease, which in most cases affects only one joint (monoarthritis), most commonly the big toe. Gout is a metabolic disorder, which primarily occurs in males. Gout is mainly hereditary in nature. The depositions of these crystal urates are known as tophi.

Signs and Symptoms

The classic picture is of excruciating and sudden pain, swelling, redness, warmness and stiffness in the joint. Low-grade fever may also be present. The patient usually suffers from two sources of pain. The crystals inside the joint cause intense pain whenever the affected area is moved. The inflammation of the tissues around the joint also causes the skin to be swollen, tender and sore even if it is slightly touched. For example, a blanket draping over the affected area would cause extreme pain.

The doctor diagnoses the presence of gout by the appearance of the afflicted joint and by the description of the symptoms by the patient. Definitive diagnosis is made by examining a sample of the joint fluid under a microscope and along with demonstration of hyperuricemia.

Stages of gout

Gout has four distinct stages:

• Asymptomatic
• Acute
• Intercritical
• Chronic

Treatment is by administering colchicine either IV or orally. Other drugs prescribed are diclofenac, phenylbutazone, probenecid, sulindac, and indomethacin. Acute attacks of gout can be prevented by administering sulfinpyrazone or allopurinol (Lopurin or Zyloprim).

Surgery
For extreme cases of gout, surgery may be necessary to remove large tophi and correct joint deformity.

Diet
Low purine diet

To lower uric acid:

• Cherries have been shown to reduce uric acid
• Strawberries or blueberries (and other dark red/blue berries) are also reputed to be beneficial
• Celery extracts (celery or celery seed either in capsule form or as a tea) is believed by many to reduce uric acid levels (although these are also diuretics).
• Limit food high in protein such as meat, fish, poultry, or tofu to 8 ounces a day. Avoid entirely during a flare up.

Food to avoid:

• Foods high in purines, that is, high in DNA
• Sweetbreads, kidneys, liver, brains, or other offal meats
• Sardines
• Anchovies
• Scallops
• Alcohol, especially beer because brewer's yeasts are very rich in purine (alcohol may also reduce the rate of uric acid excretion).
• Meat extracts, consommés, and gravies
• Diet sodas (these act as diuretics in many people, causing uric acid to concentrate in the blood which can then easily precipitate)

To avoid dehydration:

Drink plenty of liquids, especially water, to dilute and assist excretion of urates;

Use sparingly diuretic foods or medicines like aspirin, vitamin C, tea and alcohol.

When cartilage, the tough fibrous material covering the ends of the bone, is eroded at a rate faster than the body can repair, this is known as arthritis. Arthritis, or inflammation of the joints, can develop because of aging, wear and tear, or infections. Osteoarthritis or degenerative joint disease is the most common type of arthritis. Rheumatoid arthritis, on the other hand, is systemic and affects the blood vessels, heart, and other organs.

Arthritis can be caused from strains and injuries caused by repetitive motion, sports, overexertion, and falls. Unlike the autoimmune diseases, osteoarthritis largely affects older people and results from the degeneration of joint cartilage. Other forms are discussed below.

Arthritic joints can be sensitive to weather changes. The increased sensitivity is thought to be caused by the affected joints developing extra nerve endings in an attempt to protect the joint from further damage.

Signs
All arthritides feature pain, which is generally worse in the morning and on initiating movement, and resolves in the course of time. In elderly people and children, the pain may not be the main feature, and the patient simply moves less (elderly) or refuse to use the affected limb (children).

Types of arthritis

Primary forms of arthritis:

Secondary to other diseases:

Diseases that can mimic arthritis:

Diagnosis
The various types of arthritis can be distinguished by the pace of onset, the age and sex of the patient, the amount of (and which) joints affected, additional symptoms such as psoriasis, iridocyclitis, Raynaud's phenomenon, and rheumatoid nodules, and other clues.

Blood tests and X-rays of the affected joints are often performed to make the diagnosis. X-rays can show erosions or bone appositions.

Screening blood tests: full blood count, electrolytes, renal function, liver enzymes, calcium, phosphate, protein electrophoresis, C-reactive protein and the erythrocyte sedimentation rate (ESR). Specific tests are the rheumatoid factor, antinuclear factor (ANF), extractable nuclear antigen and specific antibodies whenever the ANF is found to be positive.

Treatment
Treatment options vary depending on the precise condition, but include surgery, and drug treatment, reduction of joint stress, physical and occupational therapy, and pain management.

• Pierre Marie-Bamberger syndrome (hypertrophic pulmonary osteoarthropathy, a paraneoplastic phenomenon of lung cancer)
• Multiple myeloma
• Osteoporosis
• Henoch-Schönlein purpura
• Psoriatic arthritis
• Reiter's syndrome
• Reactive arthritis
• Hemochromatosis
• Hepatitis
• Wegener's granulomatosis (and many other vasculitis syndromes)
• Familial Mediterranean fever (FMF), HIDS (hyperimmunoglobulinemia D and periodic fever syndrome) and TRAPS (TNF-alpha receptor associated periodic fever syndrome).
• Rheumatoid arthritis
• Osteoarthritis
• Gout and pseudogout
• Juvenile arthritis
• Still's disease
• Ankylosing spondylitis
• Arthritis
• Systemic lupus erythematosus (SLE) Septic arthritis