A 54-year-old man is diagnosed as having gout. You are discussing ways to help prevent future attacks.
Which one of the following is most likely to precipitate an attack of gout?
Correct Answer D: Foods to avoid include those high in purines e.g. Liver, kidneys, seafood, oily fish (mackerel, sardines) and yeast products.
Gout: management: Gout is a form of microcrystal synovitis caused by the deposition of monosodium urate monohydrate in the synovium. It is caused by chronic hyperuricaemia (uric acid > 450 μmol/l).
Acute management:
Allopurinol prophylaxis - see indications below:
Indications for allopurinol*:
Lifestyle modifications:
*Patients with Lesch-Nyhan syndrome often take allopurinol for life.
A 45-year-old man presents with a painful, swollen and red left middle toe. There is no history of trauma and his symptoms have been present for around a week.
Which one of the following conditions is most associated with this presentation?
Correct Answer E:
Dactylitis:
A 27-year-old woman is referred to orthopaedics. Three years she had surgery and chemotherapy for thyroid cancer. Follow up scans to date have shown no evidence of any disease recurrence. For the past two months she has been experiencing gradually increasing pain in her right hip which is worse on exercising. On examination passive movement of the hip is painful in all directions, especially internal rotation. An x-ray ordered by her GP has been reported as normal.
What is the most likely diagnosis?
Correct Answer B: Initial x-rays are often normal in patients with a-vascular necrosis, but it would be unlikely that metastatic deposits significant enough to cause pain would not be shown.
Avascular necrosis:
Avascular necrosis (AVN) may be defined as death of bone tissue secondary to loss of the blood supply. This leads to bone destruction and loss of joint function. It most commonly affects the epiphysis of long bones such as the femur.
Causes:
Features:
Investigation:
A 73-year-old man presents pain in his right thigh. This has been getting progressively worse for the past 9 months despite being otherwise well. An x-ray is reported as follows:
Bloods tests show:
What is the most appropriate action?
Correct Answer E: This patient has Paget's disease as evidenced by an isolated rise in ALP and characteristic x-ray changes. As he has bone pain he should be treated with bisphosphonates. A PSA of 4.4 ng/ml is probably normal in a 73-year old man and is certainly not consistent with metastatic prostate cancer.
Paget's disease of the bone:
Paget's disease is a disease of increased but uncontrolled bone turnover. It is thought to be primarily a disorder of osteoclasts, with excessive osteoclastic resorption followed by increased osteoblastic activity. Paget's disease is common (UK prevalence 5%) but symptomatic in only 1 in 20 patients.
Predisposing factors:
Clinical features - only 5% of patients are symptomatic:
Indications for treatment include bone pain, skull or long bone deformity, fracture, periarticular Paget's:
Complications:
*Usually normal in this condition but hypercalcaemia may occur with prolonged immobilization.
A 25-year-old man presents with a painful, swollen left knee. He returned 4 weeks ago from a holiday in Spain. There is no history of trauma and he has had no knee problems previously. On examination he has a swollen, warm left knee with a full range of movement. His ankle joints are also painful to move but there is no swelling.On the soles of both feet you notice a waxy yellow rash.
Correct Answer D: The rash on the soles is keratoderma blenorrhagica. His reactive arthritis may be secondary to either gastrointestinal infection or Chlamydia.
Reactive arthritis: features:
Reactive arthritis is one of the HLA-B27 associated seronegative spondyloarthropathies. It encompasses Reiter's syndrome, a term which described a classic triad of urethritis, conjunctivitis and arthritis following a dysenteric illness during the Second World War. Later studies identified patients who developed symptoms following a sexually transmitted infection (post-STI, now sometimes referred to as sexually acquired reactive arthritis, SARA).
Reactive arthritis is defined as an arthritis that develops following an infection where the organism cannot be recovered from the joint.
Around 25% of patients have recurrent episodes whilst 10% of patients develop chronic disease.
Click to expand