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{{CMG}}
__NOTOC__
__NOTOC__
==Overview==
The diagnosis of gout is based upon the identification of intracellular monosodium urate (MSU) crystals in the synovial fluid aspirate of an affected joint, under polarizing light microscopy. But when this is not possible, a clinical diagnosis can be deduced with the help of classical clinical features, including the history and physical examination, laboratory findings, and various imaging studies.
=== Diagnosis of acute gout ===
* While the favored approach is to find MSU crystals in the synovial fluid aspirate of an affected joint, in clinical practice a crystal evaluation is routinely not done<ref name="pmid21288096">{{cite journal| author=Neogi T| title=Clinical practice. Gout. | journal=N Engl J Med | year= 2011 | volume= 364 | issue= 5 | pages= 443-52 | pmid=21288096 | doi=10.1056/NEJMcp1001124 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21288096  }} </ref><ref name="pmid15014182">{{cite journal| author=Choi HK, Atkinson K, Karlson EW, Willett W, Curhan G| title=Purine-rich foods, dairy and protein intake, and the risk of gout in men. | journal=N Engl J Med | year= 2004 | volume= 350 | issue= 11 | pages= 1093-103 | pmid=15014182 | doi=10.1056/NEJMoa035700 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15014182  }} </ref>.
* When a patient is presenting with classic symptoms of rapid onset (within 24 hours), podagra, swelling, and erythema, supported by the presence of hyperuricemia, a clinical diagnosis of gout can easily be concluded. <ref>http://pubmed.gov/16707533</ref> <ref>http://pubmed.gov/18299687 <ref>http://pubmed.gov/25789770</ref>
* When an arthrocentesis is done, synovial fluid should be examined readily under routine light and polarizing light microscopy and looked for negatively birefringent needle-shaped MSU crystals. <ref>http://pubmed.gov/13773775</ref>
* In addition, testing for cell counts with differential, gram staining and culture should also be done on the aspirate.
* The sensitivity of this technique in demonstrating negatively birefringent intra- and extracellular crystals in patients with gout flares is at least 85 percent, and the specificity for gout is 100 percent. <ref>http://pubmed.gov/856219</ref> <ref>http://pubmed.gov/16462524</ref>. The sensitivity of can be further improved by examination of the sediment in a centrifuged specimen. <ref>http://pubmed.gov/10803751</ref>
{| class="wikitable" align="right"
|+ Accuracy of diagnostic criteria for gout among patients who had [[synovial fluid]] analysis
<ref name="pmid19125136">{{cite journal| author=Malik A, Schumacher HR, Dinnella JE, Clayburne GM| title=Clinical diagnostic criteria for gout: comparison with the gold standard of synovial fluid crystal analysis. | journal=J Clin Rheumatol | year= 2009 | volume= 15 | issue= 1 | pages= 22-4 | pmid=19125136 | doi=10.1097/RHU.0b013e3181945b79 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19125136  }} </ref>
! &nbsp;!! Criteria!!Sensitivity !! Specificity
|-
| ARA (ACR)||6 of 12 criteria||align="center"| 70% ||align="center"| 79%
|-
| Rome||2 of 4 criteria:<br/>&bull;&nbsp;Painful joint swelling, abrupt onset, Clearing in 1-2 weeks initially<br/>&bull;&nbsp;Serum uric acid: >7 in males; >6 in females<br/>&bull;&nbsp;Presence of tophi<br/>&bull;&nbsp;Urate crystals in synovial fluid or tissues||align="center"| 70% ||align="center"| 83%
|-
| New York||2 of 5 criteria:<br/>&bull;&nbsp;2 attacks of painful limb joint swelling<br/>&bull;&nbsp;Abrupt onset and remission in 1—2 weeks initially<br/>&bull;&nbsp;First MTP attack<br/>&bull;&nbsp;Presence of a tophus<br/>&bull;&nbsp;Response to colchicine-major reduction in inflammation within 48 h||align="center"| 67% ||align="center"| 89%
|}
Several sets of diagnostic criteria exit (see table).<ref name="pmid19125136">{{cite journal| author=Malik A, Schumacher HR, Dinnella JE, Clayburne GM| title=Clinical diagnostic criteria for gout: comparison with the gold standard of synovial fluid crystal analysis. | journal=J Clin Rheumatol | year= 2009 | volume= 15 | issue= 1 | pages= 22-4 | pmid=19125136 | doi=10.1097/RHU.0b013e3181945b79 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19125136  }} </ref>
{| class="wikitable" align="right"
|+ The serum uric acid level during an attack of gout<ref  name="pmid20625017">{{cite journal| author=Janssens HJ, Fransen J,  van de Lisdonk EH, van Riel PL, van Weel C, Janssen M| title=A  diagnostic rule for acute gouty arthritis in primary care without joint  fluid analysis. | journal=Arch Intern Med | year= 2010 | volume= 170 |  issue= 13 | pages= 1120-6 | pmid=20625017 |  url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20625017  | doi=10.1001/archinternmed.2010.196 }} </ref><ref name="pmid19369457">{{cite journal |author=Schlesinger N, Norquist JM, Watson DJ |title=Serum urate during acute gout |journal=J. Rheumatol. |volume=36 |issue=6 |pages=1287–9 |year=2009 |month=June |pmid=19369457 |doi=10.3899/jrheum.080938 |url=http://www.jrheum.org/cgi/pmidlookup?view=long&pmid=19369457 |issn=}}</ref>
! &nbsp;!! Sensitivity !! Specificity
|-
| > 5.88 mg/dl<ref  name="pmid20625017"/>|| align="center"|95%|| align="center"|53%
|-
| ≥ 6 mg/dl<ref name="pmid19369457"/>||align="center"| 86% ||align="center"| ?
|-
| ≥ 8 mg/dl<ref name="pmid19369457"/>|| align="center"|68% || align="center"|?
|}
A [[clinical prediction rule]] ([http://www.umcn.nl/Research/Departments/eerstelijnsgeneeskunde/Pages/Jichtcalculator.aspx online link]) found that the following predicted urate crystals by aspiration:<ref  name="pmid20625017">{{cite journal| author=Janssens HJ, Fransen J,  van de Lisdonk EH, van Riel PL, van Weel C, Janssen M| title=A  diagnostic rule for acute gouty arthritis in primary care without joint  fluid analysis. | journal=Arch Intern Med | year= 2010 | volume= 170 |  issue= 13 | pages= 1120-6 | pmid=20625017 |  url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20625017  | doi=10.1001/archinternmed.2010.196 }} </ref>
* Male
* Onset within one day
* Joint redness
* First metatarsaophalangeal joint
* Previous arthritis attack per patient
* History of hypertension or 1 or more [[cardiovascular disease]]s
* Serum [[uric acid]] level > 5.88 mg/dl
However, among patients with high scores, 20% did not have crystals. Only one of 381 patients had bacterial arthritis.


{{CMG}}; {{AE}}
{{CMG}}; {{AE}}

Latest revision as of 22:07, 28 May 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]


Overview

The diagnosis of gout is based upon the identification of intracellular monosodium urate (MSU) crystals in the synovial fluid aspirate of an affected joint, under polarizing light microscopy. But when this is not possible, a clinical diagnosis can be deduced with the help of classical clinical features, including the history and physical examination, laboratory findings, and various imaging studies.

Diagnosis of acute gout

  • While the favored approach is to find MSU crystals in the synovial fluid aspirate of an affected joint, in clinical practice a crystal evaluation is routinely not done[1][2].
  • When a patient is presenting with classic symptoms of rapid onset (within 24 hours), podagra, swelling, and erythema, supported by the presence of hyperuricemia, a clinical diagnosis of gout can easily be concluded. [3]
  • When an arthrocentesis is done, synovial fluid should be examined readily under routine light and polarizing light microscopy and looked for negatively birefringent needle-shaped MSU crystals. [4]
  • In addition, testing for cell counts with differential, gram staining and culture should also be done on the aspirate.
  • The sensitivity of this technique in demonstrating negatively birefringent intra- and extracellular crystals in patients with gout flares is at least 85 percent, and the specificity for gout is 100 percent. [5] [6]. The sensitivity of can be further improved by examination of the sediment in a centrifuged specimen. [7]
Accuracy of diagnostic criteria for gout among patients who had synovial fluid analysis [8]
  Criteria Sensitivity Specificity
ARA (ACR) 6 of 12 criteria 70% 79%
Rome 2 of 4 criteria:
• Painful joint swelling, abrupt onset, Clearing in 1-2 weeks initially
• Serum uric acid: >7 in males; >6 in females
• Presence of tophi
• Urate crystals in synovial fluid or tissues
70% 83%
New York 2 of 5 criteria:
• 2 attacks of painful limb joint swelling
• Abrupt onset and remission in 1—2 weeks initially
• First MTP attack
• Presence of a tophus
• Response to colchicine-major reduction in inflammation within 48 h
67% 89%

Several sets of diagnostic criteria exit (see table).[8]

The serum uric acid level during an attack of gout[9][10]
  Sensitivity Specificity
> 5.88 mg/dl[9] 95% 53%
≥ 6 mg/dl[10] 86% ?
≥ 8 mg/dl[10] 68% ?

A clinical prediction rule (online link) found that the following predicted urate crystals by aspiration:[9]

  • Male
  • Onset within one day
  • Joint redness
  • First metatarsaophalangeal joint
  • Previous arthritis attack per patient
  • History of hypertension or 1 or more cardiovascular diseases
  • Serum uric acid level > 5.88 mg/dl

However, among patients with high scores, 20% did not have crystals. Only one of 381 patients had bacterial arthritis.


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor(s)-in-Chief:

HISTORICAL PERSPECTIVE:

  • There is limited historical perspective for shock.

Definition:

Shock is defined as decrease in the oxygen delivery to the cells and tissues due to either increase in oxygen demand, decrease in oxygen consumption, inadequate oxygen utilization or a combination of these processes.

Classification:

  • Distributive shock
  • Obstructive shock
  • cardiogenic shock
  • Hypovolemic shock

Causes:

Pathophysiology:


Characteristics of forms of shock
Types of shock CVP PCWP CARDIAC OUTPUT SYSTEMIC VASCULAR RESISTANCE
Distributive decrease decrease increase decrease
cardiogenic increase increase decrease increase
obstructive increase may increase or decrease decrease increase
hypovolemic decrease decrease decrease increase


 
 
 
 
 
 
 
shock
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
cold clammy extremities
 
 
 
 
warm bounding extremities
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low cardiac output
 
 
 
 
high cardiac output
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
inc JVP,crackes
 
Dec JVP,orthostasis
 
 
septic shock,liver failure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
cardiogenic shock
 
hypovolemic shock
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
antibiotics,IV fluids
 
 
 
 
 
 
 
evaluate for MI
 
IV fluids
 
 
 
 
 
 
 
 
 

OVERVIEW

  1. Neogi T (2011). "Clinical practice. Gout". N Engl J Med. 364 (5): 443–52. doi:10.1056/NEJMcp1001124. PMID 21288096.
  2. Choi HK, Atkinson K, Karlson EW, Willett W, Curhan G (2004). "Purine-rich foods, dairy and protein intake, and the risk of gout in men". N Engl J Med. 350 (11): 1093–103. doi:10.1056/NEJMoa035700. PMID 15014182.
  3. http://pubmed.gov/16707533
  4. http://pubmed.gov/13773775
  5. http://pubmed.gov/856219
  6. http://pubmed.gov/16462524
  7. http://pubmed.gov/10803751
  8. 8.0 8.1 Malik A, Schumacher HR, Dinnella JE, Clayburne GM (2009). "Clinical diagnostic criteria for gout: comparison with the gold standard of synovial fluid crystal analysis". J Clin Rheumatol. 15 (1): 22–4. doi:10.1097/RHU.0b013e3181945b79. PMID 19125136.
  9. 9.0 9.1 9.2 Janssens HJ, Fransen J, van de Lisdonk EH, van Riel PL, van Weel C, Janssen M (2010). "A diagnostic rule for acute gouty arthritis in primary care without joint fluid analysis". Arch Intern Med. 170 (13): 1120–6. doi:10.1001/archinternmed.2010.196. PMID 20625017.
  10. 10.0 10.1 10.2 Schlesinger N, Norquist JM, Watson DJ (2009). "Serum urate during acute gout". J. Rheumatol. 36 (6): 1287–9. doi:10.3899/jrheum.080938. PMID 19369457. Unknown parameter |month= ignored (help)