Pbl Nyeri Sendi

4. What are the differential diagnose of the scenario ? ANSWER: 1. 2. . 4.

Gout Gouty y arth arthri riti tiss Oste Osteoa oart rthr hrit itis is Rheu Rheu!a !ato toid id arth arthri riti tiss "seud seudog ogou outt

GO#$% AR$&R'$'S

A. DEFINITION DEFINITION OF GOUTY GOUTY ARTH ARTHRITIS RITIS Gout Gouty y arth arthri riti tiss or arth arthri riti tiss pira pirall is an infl inflam amma mati tion on of the the oin oints ts as a manifestation of the a!!umulation of monoso"ium urate !rystals pre!ipitate# $hi!h is !oll !olle! e!te te" " in the the oin ointt as a resu result lt of the the hi%h hi%h le&e le&els ls of uri! uri! a!i" a!i" in the the 'loo 'loo" " (hyperuri!emia). Not e&eryone $ith hyperuri!aemia is piral arthritis sufferer or are suff sufferi erin% n% from from arth arthri ritis tis piral piral.. Ho$e Ho$e&e &er# r# the the ris* ris* is %reat %reater er $ith $ith arth arthrit ritis is pira pirall menin%atnya 'loo" uri! a!i" !on!entration. +. E,ID E,IDEE-IO IOO OGY GY Gout is a "ominant "isease in ol"er men. As it is state" 'y Hippo!rates that %out is rare in men prior to a"oles!en!e an" in $omen# rarely 'efore menopause. In /012 the reporte" pre&alen!e of %out in the Unite" States is /3.2 4 /#555 men an" 2.6 4 /#555 $omen. The pre&alen!e of %out in!reases $ith in!reasin% stan"ar" of li&in%. The pre&alen!e amon% Afri!an Ameri!an men is hi%her !ompare" $ith 7au!asian men. (E"$ar" Stephen# 85/5). In In"onesia there are many pu'li!ations a'out artitis %out epi"emiolo%y (A,). In /039 a Dut!h national physi!ian name" :an :an "er Horst has reporte" /9 patients $ith %out artitis "isa'ility of an area in 7entral ;a&a. Another assessment foun" that the treatment of %out patients on a&era%e ha" suffere" from the "isease for more than fi&e years. This may 'e "ue to a lot of %out patients $ho treat themsel&es. One stu"y lon% in -assa!husetts re!ei&e" more than /< of the population $ith uri! a!i" le&els of less than = m% 4 /55ml>&e %ot artitis a!ute %out atta!*s. 7. ETIO IOOGY Fa!tors that influen!e as a !ause of %out are? a. Here"itary Here"itary fa!tors fa!tors $ith a history history of %out %out in the the family family tree tree

 '. In!rease" le&els of uri! a!i" as a "iet hi%h in protein an" other foo"s ri!h in purine !ompoun"s. ,urines are !ompoun"s that $ill 'e reforme" into uri! a!i" in the  'o"y !. E@!essi&e al!ohol !onsumption# 'e!ause al!ohol is one of the sour!es of purines also !an inhi'it the "is!har%e of urine throu%h the *i"neys. ". The resistan!e of the remo&al of uri! a!i" "ue to !ertain "iseases# espe!ially renal impairment. ,atients are a"&ise" to "rin* plenty of flui"s in the num'er .minum mu!h as 8 liters of $ater or more ea!h "ay to help "isposal &eins# an" minimie "eposition of urate in the urinary tra!t. e. Use of !ertain me"i!ations that in!rease uri! a!i" le&els# espe!ially "iureti!s (furosemi"e an" hy"ro!hlorothiai"e) f. Other fa!tors su!h as stress# "iet# inury to the oints# hi%h 'loo" pressure an" e@!essi&e e@er!ise. (:itaHealth# 855=) D. ,ATHO,HYSIOOGY In!rease" serum uri! a!i" le&els !an 'e !ause" 'y e@!essi&e formation or a "e!rease in the se!retion of uri! a!i"# or 'oth. Uri! a!i" is the final pro"u!t of purine meta'olism.  Normally# the meta'olism of purines into uri! a!i" !an 'e e@plaine" as follo$s? /) De no&o path$ay in&ol&es purine synthesis an" then uri! a!i" pre!ursor  nonpurin. The su'strate initially is ri'oseB9Bphosphate# $hi!h is !on&erte" throu%h a series of interme"iates into mu*leoti"a purine (sinosinat a!i"# %uanilat a!i"# a!i" !y!lase). This path$ay is !ontrolle" 'y a series of !omple@ me!hanisms# an" there are se&eral enymes $hi!h !atalye rea!tions are? 9B fosfori'osilpirofosfat

(,R,,)

synthetase

an"

ami"ofosfori'osiltransferase

(ami"oB,RT). There is a me!hanism of fee"'a!* inhi'ition 'y purine nu!leoti"es forme"# $hose fun!tion is to pre&ent e@!essi&e pem'enu*an. 8) Austerity path$ay is the path throu%h the formation of purine nu!leoti"es  purines free a!i"# nu!lei! sol&er# or foo" inta*e. This path is not throu%h interme"iaries su!h su'stan!es lane "e no&o.'asa free purines (a"enine# %uanine# hypo@anthine) 'er*on"enasi $ith ,R,, to form a purine nu!leoti"e pre!ursors of uri! a!i". This rea!tion is !atalye" 'y t$o enymes? hypo@anthine %uanine  phosphori'osyltransferase (HG,RT) an" a"enine phosphori'osyltransferase (A,RT).

Uri! a!i" is forme" from the purine metaolisme $ill freely filtere" 'y the %lomerulus an" rea'sor'e" in the pro@imal tu'ule of the *i"ney. A small portion of  uri! a!i" is rea'sor'e" an" then e@!rete" in the "istal nephron an" e@!rete" throu%h the urine. In %out arthritis# there is interferen!e $ith meta'oli! 'alan!e (formation an" e@!retion) of %out in!lu"e the follo$in%. a. De!rease in uri! a!i" e@!retion in i"iopathi!  '. De!rease in uri! a!i" e@!retion se!on"ary# su!h as *i"ney failure. 3) In!rease" pro"u!tion of uri! a!i"# for e@ample !ause" 'y a tumor ($hi!h in!reases !ellular turno&er) or in!rease" synthesis of purines (for "efe!t enymes or inhi'itory fee"'a!* me!hanisms that play a role). 6) In!reasin% the inta*e of foo"s !ontainin% purines In!rease" pro"u!tion or 'arriers $ill in!rease the e@!retion of uri! a!i" le&els in the 'o"y. Uri! a!i" is a su'stan!e $hose solu'ility is so lo$ that ten" to form !rystals. Uri! a!i" a!!umulation at most pinne" in the form of monoso"ium urate !rystals# the me!hanism is still un*no$n. The presen!e of monoso"ium urate !rystals $ill !ause inflammation in se&eral $ays# as follo$s. /. The !rystals are a!ti&atin% the !omplement system mainly 73a an" 79a# this !omplement is emota*ti* an" $ill re!ruit neutrophils into the tissue (oints an" syno&ial mem'rane). 7rystal tri%%ers pha%o!ytosis a%ainst to@i! free ra"i!als an" leu*otrienes# primarily leu*otriene +. Death of neutrophils !ause the release of  lysosomal enymes that "estru!ti&e en"s. 8. -a!ropha%es $ere also re!ruite" to the "eposition of urate !rystals in the oint $ill perform pha%o!ytosis a!ti&ity# an" also issue" a num'er of proinflammatory me"iators su!h as IB/# IB2 IB1 an" TNF. -e"iator me"iator $ill reinfor!e the inflammatory response# in a""ition to a!ti&atin% !ells sinu&ium"an !artila%e !ells to pro"u!e protease. ,rotease this $ill !ause tissue inury. A!!umulation of !rystals of uri! urate !rystals an" re!urrent atta!*s $ill !ause the formation of "eposits su!h as $hite limestone !alle" tophi 4 tofus (tophus) "itulan% !artila%e an" oint !apsule. In the !apsule se"iment $ill tri%%er  %ranulomatous inflammatory rea!tion# $hi!h is !hara!terie" 'y masses of uri! tamorf (!rystal) surroun"e" 'y ma!ropha%es# limfosis# fi'ro'lasts# an" forei%n 'o"y

%iant !ells. ,ersiste !hroni! inflammation !an !ause fi'rosis of the syno&ium# !artila%e erosion# an" may 'e follo$e" 'y fusion oints (an*ylosin%). Tofus !an form in other pla!es (e%? ten"ons# 'ursa# soft tissue). Deposition of uri! a!i" !rystals in the renal tu'ules !an lea" to 'lo!*a%es an" nephropathy %out.

E. 7INI7A -ANIFESTATIONS 7lini!al manifestations "i&i"e" into t$o types? the typi!al %out arthritis an" %out arthritis atypi!al. a. Typi!al %out arthritis 7lini!al pi!ture really has the follo$in% properties? /. Cei%hin% arthritis atta!* has the properties !an not $al*# !an not meema*ai shoes an" "isrupt sleep. The pain is "es!ri'e" as e@tru!iatin% paint an" pea*s in 86 hours. Cithout pen%'atan at the 'e%innin% of the atta!* !an re!o&er  $ithin 3B6 "ays. 8. The atta!* is usually a si%n of inflammation monoarti*uler $ith re" is li*e # s$ollen# painful# hot# an" painful $hen mo&e". A pre"ile!tion for the firts metatarsophalan%eal (-T,B/). 3. Remission perfe!tly 'et$een a!ute atta!*s. 6. Hiperurisemia. Usually asso!iate" $ith a!ute %outy arthritis atta!*# 'ut the "ia%nosis of arthritis "oes not ha&e to 'e a!!ompanie" hiperurisemi. Flu!tuations in serum uri! a!i" pre!ipitate %out atta!*s 9. ,re!ipitant. ,re!ipitant is al!ohol# me"i!ine an" sur%ery. Usually these fa!tors are *$on sufferers.  '. Atypi!al %out arthritis Typi!al !lini!al features su!h as se&ere arthritis# monarti!ular# an" !omplete remission $as not foun". Tofi $hi!h typi!ally o!!ur se&eral epi"emi! after an a!ute atta!*. This atypi!al type rarely foun". In the fa!e of the atypi!al !ases of  %out# "ia%nosis shoul" 'e "one !arefully. For this "ia%nosis !onfirme" 'y  performin% pun!ture "pat oint flui" an" further mi!ros!opi!ally "ihat urate !rystals. In %out arthritis e&olus o'taine" four phases# as follo$s. /. Arthritis a!ute %out -anifestations of a!ute atta!*s %i&e a "istin!ti&e an" !an imme"iately ma*e

a

"ia%nosis.

The

oints

most

affe!te"

are

the

first

metatarsophalan%eal oint (=9