Case Study |
Gouty arthritis
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The patient, Mr. Li, is 54 years old this year, he began to have recurrent right ankle pain 10 years ago, and had a history of drinking alcohol and drinking old fire soup before each joint pain, and was diagnosed with gouty arthritis, when the blood uric acid level was unknown, he took colchicine and diclofenac sodium for treatment when the pain attacked, and the joint pain could be relieved in about 2 days; Despite the recurrent joint pain, Mr. Li did not go to the hospital for further examination and treatment.
After 5 years, Mr. Li's ankle pain became more frequent and lasted longer, and he had pain in many joints such as finger joints, elbow joints, knee joints, etc., and gradually grew tophi in many subcutaneous, joints and even the pinna, and the severe parts of the tophi broke down; Recently, he had multiple obvious joint pain again, and finally with the persuasion and accompaniment of his family, the patient came to the rheumatology and immunology department for treatment.
After arriving at the Rheumatology and Immunology Department, the doctor examined Mr. Li and found that he had tophi in several places:
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INVESTIGATIONS
Complete blood tests after admission:
Examination showed elevated serum uric acid: 590umol/L, combined with hyperlipidemia and hypercholesterolemia.
Tips for improving the orthostatic position of both hands and feet: 1. Bone changes in both hands, wrists and feet, considering the possibility of gouty arthritis, and bone destruction of the 5th proximal and distal phalanx on the right side; Multiple hyperdense opacities in soft tissues do not rule out the possibility of multiple tophi.
Color ultrasound examination (biphalange joints) showed multiple crystal salt deposits in the joint cavity, and "dual-track signs" and multiple tophi formations were seen, suggesting gouty arthritis sonography of multiple joints of both hands, bilateral knee joints, and multiple joints of both feet:
Further abdominal ultrasound showed fatty liver, left kidney stones
diagnosis
According to the patient's repeated episodes of acute joint pain, elevated serum uric acid, and the appearance of gouty arthritis on X-ray and B-ultrasound,
Diagnosis: gouty arthritis, tophi definitely
treat
Treatment during hospitalization: Diclofenac sodium combined with colchicine was given to control the acute attack of inflammation in the acute phase of gout attack, and Mr. Li's joint pain was well relieved, and then he was given febuxostat to lower uric acid, and the patient felt much better when he came back for a follow-up visit a week after discharge
Relevant knowledge
With the improvement of life, the prevalence of gout is getting higher and higher, and it shows a trend of younger people. What is Gout? How to control it?
Gout is a group of diseases caused by purine metabolism disorders and/or uric acid excretion disorders, which are manifested by elevated serum uric acid levels, recurrent acute arthritis, tophi and joint deformities, uric acid kidney stones and uric acid nephropathy. The most common form of gout is gouty arthritis, but in addition to joint damage, patients with gout can also have kidney disease and other manifestations of metabolic syndrome, such as hyperlipidemia, hypertension, diabetes, coronary heart disease, etc. Mr. Li, mentioned above, had hyperlipidemia on the basis of gouty arthritis, and B-ultrasound showed that he had fatty liver and kidney stones, which was consistent with the manifestations of gout comorbidities.
At present, the traditional natural history of gouty arthritis is divided into asymptomatic hyperuricemia, acute exacerbation, and interictal period, and when long-term hyperuricemia is poorly controlled, it will gradually progress to chronic gouty arthritis and tophi.
Under the normal purine diet, the blood uric acid can be diagnosed by fasting tests of more than 420umol/L twice on the same day, and some patients will have clinical manifestations of gout under the premise of hyperuricemia.
Acute exacerbations
The acute attack stage is manifested as: 1. Acute onset at midnight or early morning, severe joint pain, reaching the peak of pain within a few hours; 2. Unilateral 1st metatarsophalangeal joint is most commonly affected; 3. It can be relieved spontaneously within more than 2 weeks; 4. Colchicine has good curative effect.
Interictal periods
The interval between two acute gout attacks is usually not obvious, and the interval between two attacks is inconclusive, but as the disease progresses, the frequency of attacks gradually increases, the duration of attacks is prolonged, and the asymptomatic intervals are shortened.
Chronic gouty arthritis
and tophi lesions
Chronic arthritis is more common in patients who have not been treated standardly, and the affected joints are irregularly swollen and painful, accompanied by a large number of tophi in the joints, resulting in bone destruction in the joints.
Tophi is a characteristic manifestation of gout, mostly appearing in the pinna, around the joints, etc., and can discharge white powder or paste after breaking.
It can be seen that if gout is not well controlled, it will cause great damage to the joints, and can cause an increase in the risk of cardiovascular and cerebrovascular diseases and kidney damage, so it is very important to reasonably control the acute symptoms and maintain blood uric acid in the appropriate range after the attack of gout.
How to control a gout attack?
In fact, this is a misunderstanding, because blood uric acid fluctuations can lead to acute attacks of gout, most previous gout guidelines do not recommend the use of uric acid-lowering drugs at the beginning of the acute attack of gout, and must be used as appropriate after 2 weeks of anti-inflammatory and analgesic treatment.
Then some people will also want to ask, if you are already taking uric acid-lowering drugs regularly, do you need to stop using them when you have an acute attack of gout? According to the recommendation of the gout diagnosis and treatment standard: "If there is an acute attack of gout during stable uric acid-lowering therapy, there is no need to stop the urate-lowering drugs, and anti-inflammatory and analgesic treatment can be carried out at the same time", so if you are already taking uric acid-lowering drugs, you can continue to take uric acid-lowering drugs when you have an acute attack of gout.
Current first-line treatments used during acute gout exacerbations include: colchicine, nonsteroidal anti-inflammatory drugs, short-term hormonal therapy; Under the guidance of a doctor, you can choose the right medication to control your gout attack. The principle of acute treatment is rapid control of joint inflammation and pain. In the acute phase, bed rest should be given, the affected limb should be elevated, and drugs to control acute inflammation should be started within 24 hours of the onset, and combination therapy should be considered when monotherapy is ineffective.
The treatment of uric acid-lowering includes two parts: non-pharmacological treatment and pharmacological treatment:
Non-pharmacological treatments
The general principle of non-drug treatment is lifestyle management, first of all, limiting animal foods high in purines: animal offal, shells and sardines, etc., and reducing alcohol consumption, moderate exercise (avoid strenuous activities, strenuous activity may lead to acute gout attacks), weight loss in obese people, etc., and control hyperlipidemia, hypertension, hyperglycemia and smoking cessation. Beverages containing high fructose can increase blood uric acid, and the intake should be controlled; It is important to note that dietary control is not a substitute for urate-lowering medications.
Treatment with urate-lowering drugs
At present, the commonly used urate-lowering drugs in China include drugs that inhibit uric acid synthesis (allopurinol and febuxostat) and drugs that promote uric acid excretion (benzbromarone); Depending on the condition, different drugs may be used to control blood uric acid levels.
How much should blood uric acid be lowered? The goal of urate-lowering therapy in patients with gout is serum uric acid <360 μmol/L, which should be maintained for a long time. If the patient has developed tophi, chronic gouty arthritis, or frequent attacks of gouty arthritis, the goal of uric acid-lowering therapy is serum uric acid < 300 μmol/L until the tophi is completely dissolved and the arthritis is frequent and symptoms improve, the treatment target can be changed to serum uric acid < 360 μmol/L and maintained for a long time. At the same time, because blood uric acid also has important physiological functions, and the lower the better, the blood uric acid level should not be reduced to less than 180umol/L when uric acid is lowered.
Author: Yang Liu
Layout|Huang Yining
Audit|Zhang Jianyu
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