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A 91-year-old woman arrives by ambulance to the emergency department because she was experiencing severe pain in her right middle finger (Figure 100-1). History reveals that she has had swelling of her finger for approximately 1 year. Palpation of the distal interphalangeal joint demonstrated firmness rather than fluctuance. A radiograph of the finger was ordered (Figure 100-2). The radiograph and physical examination are consistent with acute gouty arthritis superimposed on tophaceous gout. The diagnosis was confirmed by an aspirate of the finger that demonstrated negatively birefringent, needle-like crystals, both intracellularly and extracellularly. She was given 1.2 mg of colchicine followed by a second dose of 0.6 mg after 1 hour. Her pain was markedly decreased in 4 hours. Her serum uric acid level was determined to be 10.7 mg/dL. The colchicine was used in this case because the risk of using NSAIDs was considered to be high because of her previous history of gastric bleeding secondary to NSAIDs.
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Gout is an inflammatory crystalline arthritis. Elevated uric acid leads to deposition of monosodium urate (MSU) crystals in the joints resulting in a red, hot, swollen joint. Gout typically begins as a monoarthritis, but can become polyarthritic. Treatment of acute episodes include NSAIDs, colchicine, or intraarticular steroids. Chronic therapy includes lowering the uric acid level using dietary modifications and urate-lowering drugs.
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- Gout affects 1% to 2% of the U.S. population and approximately 6% of men older than 80 years of age.1
- Gout is more prevalent in men than women.
- Gout usually begins after age 30 years in men and after menopause in women; it is familial in approximately 40% of patients.1
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- Defective uric acid metabolism with inefficient renal urate excretion leads to underexcretion of uric acid and an elevated serum uric acid level.
- Overproduction of uric acid, instead of underexcretion, occurs in approximately 10% of patients with gout, and also leads to elevated serum uric acid levels.
- Elevated serum uric acid leads to deposition of MSU crystals in the joints and the kidneys.
- Crystals trigger proinflammatory cytokines, which cause local inflammation, tissue necrosis, fibrosis, and subchondral bone destruction.
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- Medications that cause hyperuricemia—Thiazide diuretics, cyclosporine, aspirin (<1 g/day).2
- Conditions associated with gout—Insulin resistance, obesity, hypertension, hypertriglyceridemia, hypercholesterolemia, congestive heart failure, ...