Gout

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Gout
Diagnosis in short

Gouty tophus. H&E stain.

LM urate crystals - considered gold standard (see crystals in body fluids) not seen on formalin fixed sections, tophi (granulomatous inflammation - surrounds fluffy (cotton candy-like) material), fibrotic synovium
Site joints - classically large toe

Associated Dx +/-chronic renal failure, +/-diabetes mellitus
Clinical history usually male
Symptoms joint pain
Prevalence common
Blood work urea elevated
Prognosis benign
Clin. DDx other causes of joint pain - see arthritis
Treatment medications (NSAIDs for pain, allopurinol, colchicine)

Gout is a common benign affliction that can be disabling. It occasionally is seen by pathologists. It can be grouped in conditions with crystals in body fluids.

General

  • Classically afflicts the big toe - known as podagra.

Epidemiology:[1]

  • Male (Females relative risk ~ 0.1).
  • Renal failure.
  • Diabetes mellitus.

Etiology:[2]

  • Overproduction of uric acid ~ 10% of cases.
  • Reduced excretion of uric acid ~ 90% of cases.
    • May be genetic, e.g. URAT1 mutation.[3][4]
    • Renal failure.

Treatments:[5]

  • NSAIDs.
  • Allopurinol.
  • Colchicine - prophylatic.

Gross/radiology

  • Radiologically may mimic anconeus epitrochlearis muscle.[6]

DDx:

Microscopic

Features:[7]

  • Tophi (advanced)
    • Reactive granulomatous inflammation.
      • Surrounds fluffy (cotton candy-like) material.
    • Fibrotic synovium.
  • Aggregates of urate crystals - considered gold standard.[8]

Note:

Images

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Submitted as "Left Olecranon Bursa", Excision: 
     - Consistent with gouty tophus; amorphous material with granulomatous reaction.

See also

References

  1. Wang, Y.; Yan, S.; Li, C.; Zhao, S.; Lv, J.; Wang, F.; Meng, D.; Han, L. et al. (Mar 2013). "Risk factors for gout developed from hyperuricemia in China: a five-year prospective cohort study.". Rheumatol Int 33 (3): 705-10. doi:10.1007/s00296-012-2439-8. PMID 22544037.
  2. Mitchell, Richard; Kumar, Vinay; Fausto, Nelson; Abbas, Abul K.; Aster, Jon (2011). Pocket Companion to Robbins & Cotran Pathologic Basis of Disease (8th ed.). Elsevier Saunders. pp. 634. ISBN 978-1416054542.
  3. Online 'Mendelian Inheritance in Man' (OMIM) 607096
  4. Tin, A.; Woodward, OM.; Kao, WH.; Liu, CT.; Lu, X.; Nalls, MA.; Shriner, D.; Semmo, M. et al. (Oct 2011). "Genome-wide association study for serum urate concentrations and gout among African Americans identifies genomic risk loci and a novel URAT1 loss-of-function allele.". Hum Mol Genet 20 (20): 4056-68. doi:10.1093/hmg/ddr307. PMID 21768215.
  5. Eggebeen, AT. (Sep 2007). "Gout: an update.". Am Fam Physician 76 (6): 801-8. PMID 17910294.
  6. URL: http://radiology.casereports.net/index.php/rcr/article/viewArticle/57/213. Accessed on: 7 August 2011.
  7. URL: http://pathologyoutlines.com/joints.html#gout. Accessed on: 5 August 2011.
  8. Ting, K.; Graf, SW.; Whittle, SL. (Jul 2015). "Update on the diagnosis and management of gout.". Med J Aust 203 (2): 86-8. PMID 26175247.
  9. Shidham, V.; Chivukula, M.; Basir, Z.; Shidham, G. (Aug 2001). "Evaluation of crystals in formalin-fixed, paraffin-embedded tissue sections for the differential diagnosis of pseudogout, gout, and tumoral calcinosis.". Mod Pathol 14 (8): 806-10. doi:10.1038/modpathol.3880394. PMID 11504841.