Tuesday 12 June 2012

DR BINOY



RHEUMATOLOGIST IN KERALA

DR BINOY J PAUL

CEO DR .BINOY'S ARTHRITIS AND RHEUMATOLOGY CENTRE
 PHONE NUMBERS 04952740195,9249274681

Crystal Arthritis - Past, Present and Future Binoy J. Paul



T h e   c r y s t a l   r e l a t e d   a r t h r o p a t h i e s   r e p r e s e n t   a
heterogenous group of disorders in which minerals are
d e p o s i t e d   i n  mu s c u l o s k e l e t a l   t i s s u e   r e s u l t i n g   i n
pathological alterations. Intra articular crystals can cause
acute and chronic inflammation and joint damage via
biomechanical and biochemical pathways.The most
common crystal related arthopathies are Gout, Calcium
pyrophosphate dihydrate disease (pseudogout) and
calcific periarthritis/ tendonitis (Basic calcium phosphate
crystal deposition disease). Of these gout is the most
common but easily misdiagnosed problem in day to day
practice. “ Screw up the vice as tightly as possible - you
have rheumatism, give it another turn and that is gout”
-  Anonymous
The word Gout is derived from the latin word ‘gutta’
means drop. It is based on the ancient belief that the
arthritis is due to deposition of malevolent humor by
evil spirits into the joint, drop by drop (1). Way back in
the 4
th
 century BC, Hippocrates made astute observations
about gout which is popularly known as “aphorisms of
gout” He said that “Eunuchs do not take gout, nor become
bald. A women does not take gout unless her menses be
stopped,An young man does not take gout unless he
indulges in coitus. In gouty affection, inflammation
subsides in 40 days”. In 3rd century BC, Galen described
the tophi. Crystals  in gouty tophi was first demonstrated
by Antony Van Leeuwenhoek in 1679 (2). It is in 1848
Sir Alfred Garrod demonstrated hyperuricemia as the
basic cause of gout (3). In 1961 McCarty and Hollander
established the association between  gouty arthritis and
articular crystal deposition
Gout is a clinical syndrome occurs as a result of
deposition of monosodium urate monohydrate crystals
from hyper uricemic body fluids. The crystals may be
deposited in a joint leading to an acute inflammatory
response or in soft tissues such as cartilage causing no
inflammation. Most cases of gout are characterised by the
sudden onset of severe acute mono arthritis in a peripheral
joint in the lower limb. The arthritis remits completely
and  then  r e cur s  wi th  inc r e a s ing  f r equency.  Af t e r
approximately 10 years of recurrent gouty arthritis, tophi
develop in cartilage, tendons and bursae in some patients.
There is a marked increase in incidence of gout in
certain parts of  India like Kerala in the recent years.
Rapid urbanisation with change in lifestyle leading to
obesity, lack of physical exercise, high protein diet,
alcoholism and increasing use of drugs like  thiazides
are some of the causes for this rise in the  incidence.
Gout was extremely rare in menstruating females due
to the uricosuric effect of estrogen. However the
incidence of female gout is also rising in India due to
increased longevity after menopause ,change in life style,
increasing number of hysterectomies and use of various
hyperuricemic drugs
The gold standard for diagnosis of gout is joint
aspiration and identification of characteristic needle
s h a p e d   n e g a t i v e l y   b i r e f r i n g e n t   m o n o   s o d i u m
nitrate crystals under compensated polarized light
microscopy (4). Gram stain and culture of the aspirated
fluid are often performed concomitantly to exclude septic
arthritis and cellulites both of which may mimic acute
gout. When crystals are not identified and culture is
negative a presumptive diagnosis of gout is often made
on the basis of other factors including a classic clinical
presentation ( eg. Podagra) positive family history, hyper
ur i c emi a   and  r apid  r e solut ion of   symptoms  wi th
colchicine.