Crystals in the joint cause gout and pseudogout


Both gout and pseudogout manifest as a painful, red swelling over a joint. — Dr YEAP SWAN SIM

The term “arthritis” means inflammation or swelling of one or more of our joints.

It can be due to various conditions affecting the joints, tissues around the joint, or other connective tissues.

These conditions include osteoarthritis, rheumatoid arthritis, fibromyalgia and gout.

The symptoms usually develop over time, but they may also appear suddenly and affect one’s ability to perform daily tasks.

In Malaysia, gout is one of the most common conditions causing arthritis, predominantly affecting men and postmenopausal women.

Gout

Gout is caused by the formation of uric acid crystals (the orange and blue needle shapes seen here under a microscope) in joints. — Photos: Wikimedia CommonsGout is caused by the formation of uric acid crystals (the orange and blue needle shapes seen here under a microscope) in joints. — Photos: Wikimedia Commons

Gout can be considered a disorder of metabolism as it occurs when the body makes too much uric acid or removes too little uric acid.

The uric acid build-up in our blood can lead to the formation of needle-shaped urate crystals in the joint, causing severe attacks of pain, swelling, redness and tenderness.

Uric acid is produced when our body breaks down purines.

Purines are chemical substances that can be found naturally in our body and some foods.

Purine-rich foods include red meat, liver, seafood and shellfish.

High intake of alcoholic beverages and drinks sweetened with fruit sugar (fructose) also increases serum uric acid level.

Besides the consumption of a purine-rich diet, there are several other factors that may increase the risk of gout.

These are:

  • Body weight

    Serum uric acid level is higher in people who are overweight or obese.

  • Ageing and gender

    The risk of gout is generally high among men, who are also more likely to develop this condition at an earlier age – between 30 and 50 years old – compared to women.

    Most women tend to develop gout after menopause, as they tend to have lower uric acid levels before that.

  • Family history

    Genetic factors may predispose a person to gout.

  • Underlying conditions

    Untreated high blood pressure and chronic conditions such as diabetes, obesity, heart and kidney diseases, increase the risk of gout.

  • Drugs

    Low-dose aspirin and some medications used to control hypertension, including thiazide diuretics, angiotensin-converting enzyme (ACE) inhibitors and beta blockers, may also increase uric acid levels.

  • Recent surgery or trauma

    Either can trigger a gout attack.

A gout flare almost always occurs suddenly, and often at night.

It often affects the big toe, but can also occur in any joint of the ankles, knees, elbows, wrists or fingers.

Symptoms in the affected joints include intense pain, swelling, redness and heat.

Even after the severe pain subsides, lingering discomfort in some joints may last from a few days to few weeks.

Pseudogout

It sounds like gout, it looks like gout, but it is not gout.Pseudogout is caused by the deposition of calcium pyrophosphate crystals (the orange and blue rhomboid shapes seen here under a microscope) in joints.Pseudogout is caused by the deposition of calcium pyrophosphate crystals (the orange and blue rhomboid shapes seen here under a microscope) in joints.

Confused?

Pseudogout, as its name implies, is also a form of arthritis that has many of the same symptoms as gout.

They are also both caused by the accumulation of crystals in the joints.

However, pseudogout is caused by intra-articular calcium pyro- phosphate crystal deposition, unlike gout, which is caused by the accumulation of urid acid crystals.

Among the risk factors for pseudogout are:

  • Ageing

    Most people who develop pseudogout are 60 or older.

  • Family history or genetic disorder

    Genetics may play a role in making a person more prone to accumulating calcium pyrophosphate crystals in their joints.

    This makes them more likely to develop pseudogout at a younger age.

  • Joint trauma

    Trauma to a joint, such as a serious injury or surgery, may in- crease the risk of pseudogout in that particular joint.

  • Underlying conditions

    Metabolic and endocrine disorders such as hyperparathyroidism, haemochromatosis, hypophosphatasia and hypomagnesaemia, may predispose a person to pseudogout.

Pseudogout typically presents with attacks of joint pain, joint stiffness and swelling.

It most commonly affects the knees, and less often involves the wrists and ankles.

Diagnosis

The methods of diagnosis for both gout and pseudogout are similar, and include:

  • Synovial fluid analysis

    The gold standard for diagnosing these two conditions is synovial fluid analysis.

    A small amount of synovial fluid from the affected joint is extracted to identify the crystals by their shape, colour and reaction to light using a polarised microscope.

  • Blood and urine lab tests

    In order to rule out other potential conditions, the doctor may order blood and urine lab tests.

  • X-rays

    Calcification of cartilage due to the deposition of calcium pyro- phosphate crystals can be seen on X-rays.

    However, X-rays alone cannot be use as the diagnostic tool to diagnose pseudogout.

  • Ultrasound

    Ultrasound is useful in detecting the calcification of cartilage due to the deposition of calcium pyro- phosphate crystals.

Treatment

Red meat is a no-no for patients with gout and pseudogout as it is high in purines. — AFPRed meat is a no-no for patients with gout and pseudogout as it is high in purines. — AFP

The available treatments help to relieve pain and reduce inflammation for both gout and pseudogout include:

> Medications

Over-the-counter pain relievers and non-steroidal anti-inflammatory drugs (NSAIDs), as well as anti-inflammatory medications like colchicine and corticosteroids, are commonly used to manage both conditions.

Medications like allopurinol and febuxostat, which block uric acid production, and medications like probenecid, which improve uric acid removal, are also used to treat gout.

> Joint drainage

Removing some of the joint fluid helps to remove some crystals from the joint.

This treatment is carried in order to relieve pain and pressure in the affected joint, as well as to improve movement of the joint.

Sometimes, medication will be injected following removal of the fluid to help to reduce the inflammation.

> Lifestyle remedies

While medications are available to effectively treat gout and pseudogout attacks and prevent flares, adopting healthier lifestyle measures is also important to lower the risk of recurring attacks.

Patients should drink plenty non-alcoholic beverages, especially water, and avoid/limit alcoholic beverages and sweetened beverages containing high fruit sugar (fructose).

Maintaining a healthy weight helps to reduce the risk of gout.

Activities such as walking and swimming are preferred as these activities are easier on the joints.

Foods high in purines, such as red meat and organs, as well as purine-rich seafood like sardines, anchovies and scallops, should be avoided.

Those prone to gout are advised to consume more low-dairy pro-ducts as an alternative source of protein.

These lifestyle modifications are highly encouraged, and when combined with drug therapy, could lead to better control of both gout and pseudogout.

Dr Wendy Yeo Wai Yeng is a lecturer in biochemistry and medical biotechnology, and Dr Radha Kodiappan is a senior lecturer in molecular genetics and biochemistry, at the Perdana University Graduate School of Medicine. This article is courtesy of Perdana University. For more information, email starhealth@thestar.com.my. The information provided is for educational and communication purposes only, and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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