Wednesday, July 10, 2013

Episodic Oligoarticular Arthritis and Podagra


Podagra-severe inflammatory arthritis at the first metatarsophalangeal joint-is the most frequent manifestation of gout. Patients usually describe waking within the middle of the night with dramatic pain, redness, swelling, and warmth of the region. Flares of gout typically create one of the most intense forms of inflammatory arthritis. The toes and, to a lesser extent, the midfoot, ankles and knees are the most common websites for gout flares. Gout flares often occur in circumstances that improve serum uric acid amounts, such as metabolic stressors leading to elevated DNA or adenosine triphosphate (ATP) turnover (eg, sepsis or surgery) or dehydration.

Agents that reduce prostaglandin synthesis (eg, nonsteroidal anti-inflammatory drugs), decrease neutrophil migration into the joints (eg, colchicine), or decrease the activation of myelomonocytic cells (eg, corticosteroids) decrease the duration of the gouty flare. Gouty arthritis can be diagnosed by examination of synovial fluid from an actively inflamed joint under a polarizing microscope.

Monosodium urate crystals could be seen as negatively birefringent needle-like structures that extend across the diameter of and therefore are engulfed by polymorphonuclear neutrophils. Firm, irregular subcutaneous deposits of monosodium urate crystals may occur in individuals with chronic gout and therefore are referred to as tophi.

Tophi most frequently form along tendinous tissues on the extensor surfaces of joints and tendons as well as on the outer helix from the ear. This kind of tophi might extrude chalky material, containing urate crystals, onto the skin surface and can be viewed for diagnostic purposes under polarized microscopy. In some individuals, the total body burden of uric acid increases greatly over many years; deposits of monosodium urate crystals occur at numerous joint websites.

This may result in a persistent but more indolent inflammatory arthritis related to remodeling from the thin synovial membrane into a thickened inflammatory tissue. Destructive and irreversible joint deformities resulting from bone and cartilage erosions often produce in this circumstance. Renal tubular injury and nephrolithiasis can also produce below these problems.

Treatment for acute gouty arthritis consists of brokers that reduce inflammatory cell recruitment and activation towards the involved joints. In contrast, prevention or prophylaxis of recurrent attacks of gouty arthritis demands chronic treatment to reduce serum uric acid amounts into the normal array, exactly where dissolution of crystals is favored.

A number of brokers are obtainable that can achieve this objective. These include uricosuric agents (eg, probenecid), which improve excretion of uric acid to the urine, and allopurinol, which inhibits uric acid synthesis by inhibition of xanthine oxidase (a critical enzyme in the uric acid synthetic pathway). Xanthine oxidase inhibitors are conceptually suitable for treatment of uric acid overproducers (10% of individuals), and uricosuric agents for treating uric acid underexcretors (90% of patients).

However, brokers that decrease uric acid production can be utilized for therapy of hyperuricemia irrespective of trigger and are frequently a lot more convenient in terms of dosage regimens. Several newer recombinant molecule therapies, including an enzyme called uricase that directly breaks down uric acid, and a soluble IL-1 receptor antagonist, have shown promising early outcomes within the remedy of refractory gout.

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