Gout

Gout is a disease resulting from the violation of purinovogo exchange and characterized by the deposition of salts of uric acid (orurate) in joints, the epiphyses of the bones, the cartilage of the ears with the development of aseptic inflammation.
Etiology and pathogenesis. Sick more often than men older than 40 years. Gout is often hereditary constitutional disease, occurring in families of a number of generations. In addition to the constitutional anomalies exchange, in the development of gout are set to overeating, excessive meat, alcohol. Gout is often combined with obesity and diabetes.
Improving education or violation excretion of uric acid plays a significant role in the pathogenesis of gout. In the result of violations of purine metabolism in the blood accumulates a large amount of uric acid and its salts - uratov, which are the final product of the collapse of complex proteins (nucleoprotein).
Pathological anatomy. The most typical for gout inflammatory changes in the synovial membranes, joint capsule, tendon sheaths, cartilage, joint ends of the bones by deposition of uric acid sodium and connective tissue reaction. In the place of deposition of urate is the destruction of the articular cartilage and bone substance, which can lead to deformation of the joints and subluxations.
In the periarticular tissue on the ear lobe formed the so-called those who loves representing alopecia deposits uratov, surrounded by a ring of connective tissue. Often there urate deposition in the kidneys and other organs.

gout
Fig. 1. Those who loves on the ear.
Fig. 2. Typical "gouty brush.

The clinical picture. The disease often starts with an acute attack of gouty arthritis. In most cases the process is localized in Plesneva-phalangeal joint of the big toe; can affect other joints. The attack begins suddenly, often at night. Experiencing severe pain in the affected joint, redness and swelling. Joint area's hot to the touch, dark red and extremely painful. Appears chills, fever up to 38-40 degrees, the Language of coated, belly swollen, liver sometimes enlarged and painful bowel is not functioning. By morning the pain decreases, and at night again sharply aggravated. The attacks can occur within 3-6 days. Then inflammatory phenomena are, the function of the joint fully restored. The intervals between attacks from a few days to 1-2 years. As the disease progresses her arthritis frequent, pain in the joints do not stop even in intervals between attacks), the disease is chronic. In this phase usually observed multiple lesions of joints (Fig. 2). Occurs stiffness and deformation of the joints. Develop contractures, subluxations fingers. Is the deposition uratov with the formation of Tofa that are different in size (from 1 millimeter to several centimeters in diameter). Those who loves often located on the edge of the ears (Fig. 1), on the wings of the nose, eyelids, on the joints of the fingers and big toes. Sometimes those who loves reach large sizes, skin over them thinner, which often leads to the formation of a fistula, through which are highlighted in white crystals of uric acid salts.
Gout may be atypical without acute attacks, with gradual development of arthritic changes in the joints. Often gout accompanied by hypertension, early development of atherosclerosis in the coronary arteries and brain vessels, obesity, education in the urinary tract stones of urates. For gout is characterized by increased levels of uric acid in the blood - more than 4 mg of%. Chest x-ray shows typical round defects in the epiphyses due to the substitution of bone by urates.
The forecast. Upon the timely and systematic preventive and therapeutic measures can stop the disease progression and prevent the development of acute gouty attacks.
Treatment. In the period of acute gouty attack on 1-2 day the patient is transferred to "hungry" diet: fruit juices, tea with sugar, alkaline mineral water, biscuits. Prescribe anti-inflammatory drugs: phenylbutazone 0.15-0.2 g 4 times a day.
If gout not accompanied diabetes, apply prednisolone 20 to 30 mg per day short course (to reduce pain and swelling).
Appoint tincture Colchicum 15-20 drops 3-4 times a day. When nausea, vomiting, diarrhea the drug should be discontinued.
The chronic course the main value in the treatment of gout has diet-restriction proteins, especially meat, if enough fluids and reduced calorie (for obese patients especially). Exclude from food kidneys, brain, liver, sorrel, radish, peas, beans, spicy seasonings, limit fish. Recommend a dairy-vegetarian food, drink plenty of water. Of drugs used drugs, contributing to urate excretion: Uragan 1 teaspoon in a glass of water 3-4 times a day for 30-40 days, Itemid 0,35 g 2-6 times a day, salicylates. Shows the physiotherapy (inegalitarian with lithium, diathermy, sollux), medical gymnastics, massage. Patients with gout send to receive treatment at resorts: Pyatigorsk, Saki, Evpatoria (mud therapy), Matsesta (hydrosulphuric baths), Tskhaltubo (radon baths), Odessa (salt baths).
Prevention is the observation from General hygienic mode, rational nutrition, increasing physical activity (walking, gymnastics).

Gout (synonym: arthritis urica is a disease due to a violation of nucleic acids metabolism; characterized by high content of uric acid in the blood and repeated attacks of arthritis, accompanied by severe pain and deposits of uric acid crystals of sodium in the cartilage, tendon sheaths, mucous bags joints, sometimes in the skin, kidneys, muscles.
The etiology and pathogenesis. More common in men after age 40. Gout is often hereditary constitutional disease, occurring sometimes in families for many generations. The origin of gout, except constitutional anomalies exchange, are set to overeating, abuse of meat, alcohol, sedentary lifestyle. In the pathogenesis of gout significant role played by increased concentration in the blood uric acid salts and their deposits in the joints and other tissues, which may be related with violation of neurohumoral regulation of metabolism, allergic conditions, failure of the liver, with the local neurotrophic and vascular disorders in the Tissues.
Pathological anatomy. Uric acid salts gout fall and deposited on articular surfaces mainly small joints of the hands and feet. Salts of uric acid sodium deposited as needle-like crystals in the field of head I metatarsal bone (usually), interphalangeal joints of the brush, Golino-stop and knee joints. Often they are deposited in the articular capsule, synovial membranes, tendon sheaths, in the cartilage of the ear, in the kidneys. Occasionally crystals fall in serous and brain membranes, in the mucous membrane of the gastrointestinal tract, in the vocal cords, the cartilages of the larynx and bronchi, and valves of the heart, in the walls of the aorta and veins (visceral form of gout). Joint salt deposits appear primarily on the surface of the cartilage. In the context of articulate surfaces contain krasnovato yellowish mass and look as if covered with chalk. Fallen salt cause tissue necrosis. Around accumulation and areas of necrosis occurs inflammatory process with swelling and infiltration of tissues mainly lymphoid and plasma cells. Subsequently develops granulation tissue with giant cells foreign bodies (Fig. 1), then passing in scarring. Macroscopically the process of salt deposits with the development of granulation-scar tissue is a gouty nodes (tophi urici), significantly distorting the joints (Fig. 2). Simultaneously with the loss of cartilage in the inflammatory process involved and the synovium. Further inflammatory process can go on the epiphyses of bones. When the atom can occur microfractures in the subchondral departments bones with subsequent development of fibrous and bone blisters. The inflammatory process in joints may end in the formation of ankylosis and contractures. In gouty nodes can be further delayed and lime, as in areas of tissue necrosis (see Calcification). Occasionally there is a complete resorption of urates. They are soluble in water, so for microscopic examination is necessary fixation of the material in waterless alcohol.

Fig. 1. Gout: the accumulation of uric acid salts in the articular capsule; around granulation tissue with giant cells foreign phone
Fig. 2. Gouty nodes on the joints of the fingers.

Gout is often observed lesions of the kidneys in the form of vascular nephrosclerosis with hyalinosis glomerular sclerosis and leading arteries. In bone dystrophic changes. Kidney damage due to the fact that clubockova filter becomes passable for protein products. Another type of kidney damage gout is the deposition of urate in the parenchyma, in the epithelial cells, the Lumina tubules and in interstitial stroma. Around develop necrosis with productive inflammation and formation of giant cells foreign phone In the pelvis uric acid are formed sand and stones. In the future, may accede pyelonephritis with puckering kidneys. Macroscopically in the context of the kidneys urates visible in cerebral layer in the form of yellowish-white stripes.
In addition to violations of exogenous purine metabolism disorders can occur endogenous nature, on the ground of what may appear the so-called secondary gout (under fever, pneumonia, leukemia, malignant tumors) in connection with the decay of nuclei of cells, rich in nucleoproteins. The same disorder of purine metabolism can be in diabetes due to breakdown muscle tissue.
The clinical picture. Acute gouty attack occurs most often with the defeat of one the metatarsophalangeal joint of the thumb, less often affects several joints. Often the gout attack is preceded by neuralgia, mental depression, etc. To the attack can lead alcohol abuse, mental stress. Usually at night appear cruel pains of the affected joint, accompanied by his swelling and redness, sharp pain when touched. The attack accompanied by chills, high fever, sometimes up to 40 deg. Tongue coated, belly swollen, the action of the bowels detained, the liver is enlarged and painful. Attacks continue in 3-4 days, may be repeated at intervals of varying duration - from several months to a year.
Chronic gout. After the first attack local changes are almost completely; however further observed gradually increasing persistent changes - thickening and limited mobility of the sick joint. The soft tissue around the joint remain constantly edema, gout nodes (tophi) increase, skin over them thinner and may even break, and through fistula become prominent white mass of crystals of uric acid salts. In this form there multiple lesions of the joints. Gouty arthritis can lead to deformation due to contractures, subluxations fingers.
Atypical gout occurs mainly visceral lesions of the kidneys (arteriolosclerosis nephrosclerosis - "podagriceski wrinkled kidney), urinary tract with formation in them of sand and stones. You may experience chronic colitis, liver enlargement, the formation of stones in the bile ducts; resistant pharyngitis, laryngitis, bronchial asthma. Often gout combined with hypertension and early development of atherosclerosis of coronary and cerebral vessels.
Skin lesion for gout (tophi urici) more often in men sometimes long before other signs of illness due to deposits of uric acid salts in the dermis (lumps) or in the hypodermis (nodes). Histologically in Central elements - grained mass cholesterol, surrounded by a layer of crystals of uric acid sodium, multi-core giant cells and thick fibrous capsule of histiocytes and lymphocytes. From 36 to 70% of their content is accounted for urates. In Mature nodes blood vessels not; old can inlaid with salts of lime. The rash appears mainly in areas of slow circulation; the deposition of urate contributes to the high content of sodium in the connective tissue, heliotropism of Mukhina cartilage outer ear and a large number of free and bound uric acid in the blood. Single, less often multiple (up to 10-12), the bumps in the magnitude of lentils to a walnut located on the edge of the ears, on the rear of the joints of the fingers and hands, big toes, less often on the scalp, external genitalia, eyelids, etc. Sometimes, merging, they can form large conglomerates, complicating motion in the joints. They are soft, painless, whitish or yellowish, with brilliant hard skin, but after disturbance regime when changing atmospheric conditions increase, inflamed: there redness and soreness. Usually acute effects are in 4-6 days bumps become dense and there over the years. Some dissolve, others are opened, releasing whitish hypnovideo mass. The healing of ulcers involved scar is slow (up to several years), often re-open the fistula. Abscesses usually does not happen. Nodes occur approximately bags elbow processes, patellas, along Achilles tendon. In patients with gout often eczema, skin itching, urticarnae prurigo, sometimes hair loss on peregrinating surfaces of the legs. Xanthoma yellow-orange color. Rheumatic nodes are located symmetrically on the lateral surfaces of the joints from old people give on an x-ray shadow characteristic of calcification and limestone concretions. Small atheroma softer, localized on the face and upper body. Treatment General - see below; local recommend iontophoresis 2% solution of lithium (+ electrode). The found items scrape the acute stomach, large removed surgically.


    The diagnosis is based on a typical clinical picture of acute gouty attacks, the presence of gouty sites and typical gout defeats of other organs, increased levels of uric acid in the blood (from 5 to 18 mg% at the rate of 2 to 4 mg%) and chest x-ray. The differential diagnosis spend with rheumatic fever, rheumatoid and gonorrheal arthritis. Century Yakovlev.
X-ray diagnostics. Symptoms for gout defeat radiographically detected only in osteo-articular apparatus. They are characterized by the typical localization of destructive changes and their consequences. Uric acid salts fall in osteo-articular apparatus (Fig. 3 and 4) in the places of attachment of capsules and articular cartilage. Are affected most often the head of the first metatarsal and metacarpal bones, at least - articular ends of the fingers of feet and hands, it is rarely similar plots of other joint ends.
Bones in places of loss of uric acid salts destroyed compact matter, there are holes with roundish or oval shapes. Merging between
themselves, they form an irregular shaped parts destruction, exciting in one way or another and cancellous bone. The damage to the articular cartilage, accumulation of uric acid salts in the future to destroy a particular during the subchondral closing the record. In a sharply-cut cases violated configuration articular ends and normal relationship. In the affected joint occurs subluxation. Involved in the process adjacent sinovialnuu bag sharply increased network in the x-ray image more clear, well demarcated shadow, more intense than the adjacent soft tissue.
Periostitis, sclerosis of articular ends and marginal bone growth in the gouty defeat does not occur. Marginal bone growth are manifestations of aging.
In the USSR gouty joint injury is very rare, especially in women.

Fig. 3. Plots of destruction in the head I metatarsal.
Fig. 4. Gouty nodes in the metatarsophalangeal joint of the first finger. Regional defects in heads III and V of the metatarsal in places deposits uratov.

Forecast for life favorable, however, the development of opportunistic diseases weight forecast, leading to premature disability.
Treatment. Lacto-vegetarian diet sharp reduction of meat, meat soups and especially of liver, brain, kidneys, it is allowed to consume a small amount of boiled meat and fish. Prohibited vegetables containing purines,peas, beans, lentil, radish, sorrel, spinach, and alcohol. Appoint drinking (up to 2.5 liters per day) heavy water or liquid tea.
To accelerate the excretion of uric acid, used atavan 0.5 g 3-4 times a day cycles for 5 days weekly intervals. His drinking alkaline water. The drug is contraindicated in diseases of the liver and kidney, stomach ulcers, bronchial asthma, hay fever. In addition, apply benemid 0.5 g for 7 days, followed by 1 g / day (at the rate of 15 g). Anturan in doses of 200 to 600 mg a day contributes to the rapid decrease in the level of uric acid in the blood due to a significant increase its excretion with urine. As anti-inflammatory agents use sodium salicylate up to 6 g / day, acetylsalicylic acid up to 3 g per day, etc.,
Kortikotropina hormones effective in articular form of gout and related violations of allergic origin. ACTH appoint 10 to 15 IU 4 times a day intramuscularly to acute nephritis phenomena, then reduce the dose to 5-10 IU 4 times a day for 15-20 days. Initial doses of cortisone tablets 0.05-0.1 g 2-3 times a day with a gradual decrease in the daily dose of 0.1 g
After the occurrence of defined therapeutic effect reduce the dose to 0.05 g per day. Throughout the course of treatment give up to 5 grams of the drug. The initial dose of prednisolone 20-30 mg supporting - 5-10 mg Corticosteroids are contraindicated with hypertension, diabetes mellitus, cardiovascular decompensation. In acute gout attacks need bed rest, heat on the affected joint, excessive drinking; tincture of Colchicum (T-ra Colchici) on 15-20 drops 3-4 times a day.
Prevention. Systematic training and sufficient constant exercise, sports, rational nutrition.