tophi
Introduction
Introduction to Gout Stone In the pathogenesis of gout patients, there will be a hard, stone-like nodule called "gout stone", also known as gout nodules. This sodium urate crystal is deposited in soft tissues, causing chronic inflammation and nodular swelling of fibrous tissue. Tophi is most common in the ear wheel, and is also common in the first metatarsophalangeal joint, finger, wrist, elbow and knee joint of the toe. A small number of patients can appear in the nasal cartilage, tongue, vocal cord, eyelid, aorta, heart valve and Myocardium. Invades the bone in the bones near the joint, forming skeletal deformities, or damaging the bone. This gout nodule can also be found in the synovial membrane, tendon sheath and cartilage near the joint. The tophi is of different sizes, small as sesame and large as eggs. basic knowledge The proportion of illness: 0.001% Susceptible people: no specific population Mode of infection: non-infectious Complications: gouty arthritis
Cause
Toxstone cause
Age factor (25%):
Older people are more likely to suffer from gout than younger ones. The age of onset is about 45 years old. However, due to the general improvement in people's living standards in recent years, overnutrition and exercise have decreased, and gout is developing towards a younger age. Gout patients around the age of 30 are also common.
Dietary factors (40%):
In recent years, people's diet structure has changed significantly, especially in the 20-40 year olds, the diet containing high energy, sorghum substances increased significantly. According to statistics, more than 90% of gout patients in this age group have the habit of drinking plenty of alcohol and eating meat, animal offal, seafood and other foods rich in terpenoids.
Weight factor (15%):
Obese middle-aged men are prone to gout, especially those who do not like sports, eat more meat protein, and have more nutrients than guts.
Prevention
Tophi prevention
1. Maintain a relaxed and happy mood, strategically despise the disease, and pay attention to the disease in tactics.
2. Follow the doctor's advice, review the follow-up regularly, and reduce or stop the drug under the guidance of a doctor.
3. Avoid predisposing factors such as obesity, fatigue, dampness and nervousness.
4. Diet control: avoid sorghum diet (see attached table): eat less animal offal, seafood and thick broth; beef instead of chicken; eat more fruits (especially cherries), vegetables (asparagus, seaweed, mushrooms, etc.) Vitamin C, coffee and dairy products have a preventive effect, it is recommended to take appropriate amount.
5. Strictly quit drinking all kinds of alcohol, especially beer.
6. Drink plenty of water: >2000ml daily.
7. Lifestyle: Maintain ideal weight and exercise properly (swim, walk, etc.).
8. It is not advisable to use drugs that inhibit uric acid excretion, such as hydrochlorothiazide and furosemide.
9. Monitor blood uric acid, erythrocyte sedimentation rate, C-reactive protein, renal function and other indicators.
10. Take care to prevent and control common comorbidities such as high blood pressure, hyperlipidemia, diabetes, arteriosclerosis, coronary heart disease and stroke.
Complication
Tophi complication Complications, gouty arthritis
As the tophi is gradually enlarged, the skin on the outside may become thin and broken, forming a fistula, flowing out some cheese-like substance like lime residue, and the wound is difficult to heal. Secondary infection is rare because uric acid has the effect of inhibiting bacteria. The stones that occur near the tendons of the hands and feet, Changzhou affect joint activities and sometimes require surgery.
The hazard of tophi is thorough. It invades the bone in the bone marrow near the joint, which affects the bone marrow function, causes bone marrow malformation, or damages the bone, which affects daily life. Such as the continuous deposition of uric acid crystals on the toes, it is easy to form a huge tophi, resulting in the inability to wear shoes, walking difficulties and other consequences.
Symptom
Tophus symptoms common symptoms joint pain gout nodules uric acid crystal joint deformity
First, common in auricles and fingers, toe joints. Invading the bones in the bones near the joints, forming skeletal deformities, or damaging the bones. This gout nodule can also be found in the synovial sac, the sphincter and the cartilage near the joint. The size of the tophi is different. The symptoms of small tophi are like sand, and the big ones are like eggs. The higher the blood uric acid concentration, the longer the course of the disease, and the greater the chance of tophi. After the tophi is gradually enlarged, the skin on the outside may become thin and collapse, forming a sinus, and discharging the white urate-like urate crystals, which will not heal for a long time. Stones that occur near the tendons of the hands and feet often affect joint activity. Severe cases require surgery. In recent years, the number of effective drugs for lowering uric acid in the blood has gradually increased, and the application has gradually increased, so the appearance of tophi has been reduced. This is a nodular swelling formed by the deposition of sodium urate crystals in soft tissues causing chronic inflammation and fibrous tissue hyperplasia.
Second, the outer ear's ear, ulna olecranon, interphalangeal and metacarpophalangeal joints, fingertip skin, palm, wrist joint, toe, ankle, foot, foot, knee joint capsule and muscle health. The tophis in these areas are relatively superficial and easy to be found. Uncommon parts include nasal cartilage, epiphyseal cartilage, cornea and sclera. Occasionally, tophi can also occur on the aorta, myocardium, aortic valve, mitral valve, tricuspid valve, tongue, epiglottis, vocal cords and structural cartilage, tracheal cartilage, penis, and foreskin. It is rarely seen in the body, such as the shoulder, chest, abdomen, back, waist, buttocks, etc., thighs and upper arms are also rare. It may be that local temperature and blood circulation are better in these areas. The pH of the local tissue is higher than that of the extremities, and the urate crystals are not easily deposited in these areas, but they are not absolutely impossible. Therefore, when subcutaneous nodules are found in these areas, the possibility of tophi can not be ruled out. As far as is known, only brain tissue is formed without pain.
Examine
Check of tophi
1. Determination of blood uric acid: male blood uric acid value exceeds 7mg / dl, female over 6mg / dl is hyperuricemia.
2. Determination of uric acid: After 5 days of low-grade diet, 24-hour uric acid excretion >600 mg is excessive uric acid production (about 10%); <300 mg indicates reduced uric acid excretion (about 90%). In the normal diet, 24-hour uric acid excretion is differentiated by 800 mg, and above the above level, uric acid production is increased. This test is necessary for patients with a family history of gout, younger age, elevated blood uric acid levels, and kidney stones. Through testing, the biochemical classification of hyperuricemia can be preliminarily determined, which helps to select uric acid and determine the nature of urinary calculi.
3. Urate test: A needle-like or rod-shaped monosodium urate crystal that exhibits a negative birefringence under a polarized light microscope. Acute exacerbation can be seen in the leukocytes in the synovial fluid of the joints; it can also be seen in the aspirates in the tophi; in the episodes of seizures, it can also be seen in the synovial fluid of the affected joints.
4. Imaging examination: only acute asymmetry soft tissue swelling around the affected joint during acute attack; some atypical radiological changes may occur in the intermittent episode; the articular cartilage is caused by the deposition of monosodium urate crystals in the chronic tophus lesion Lower bone destruction, eccentric circular or ovoid cystic changes, even worm-like, piercing-like defects, clear boundaries, adjacent cortical bone can be swollen or bone-like cocked. In severe cases, the articular surface can be destroyed, causing subluxation or dislocation of the joint, and even pathological fractures; cartilage can also be destroyed, joint space gap and secondary degenerative changes and local osteoporosis occur.
5. Ultrasound examination: Ultrasound examination of the affected joint can find joint effusion, synovial hyperplasia, articular cartilage and bone destruction, tophi and calcareous deposits in or around the soft tissue of the joint. Under the ultrasound, the renal medulla, especially the cone of the cone, is scattered in the strong echo point, which indicates urate nephropathy, and urinary acidic urinary stones that are not developed under X-ray can also be found.
6. Other laboratory tests: urate kidney disease may have urinary protein, poor concentration function, urine specific gravity below 1.008, and eventually progress to azotemia and uremia.
Diagnosis
Diagnosis of tophi
Disease diagnosis
Middle-aged and older male obese people, sudden recurrent single toe, sputum, sputum and other joint redness and severe pain, can be self-relieving and intermittent asymptomatic, should first consider gouty arthritis; at the same time combined with hyperuricemia and It can be diagnosed as gout if it is effective for colchicine treatment; it can be confirmed by synovial or synovial biopsy.
Differential diagnosis
1. Identification of primary gout and secondary gout, secondary gout has the following characteristics:
1 more common among adolescents, women and the elderly;
2 high degree of hyperuricemia;
In 3 patients, 24-hour uric acid excretion increased;
4 kidney involvement is more common, and even acute renal failure occurs;
5 symptoms of gouty arthritis are often mild or atypical;
6 may have a clear history of related medications.
2. Identification with other joint lesions:
1 type of rheumatoid arthritis: generally seen in young and middle-aged women, occurs in the small joints of the extremities, manifested as symmetrical polyarthritis, the affected joints are fusiform swelling, often accompanied by morning stiffness, repeated attacks can cause joints deformity. Rheumatoid factor is more positive, but blood uric acid is not high. X-ray films showed that the articular surface roughness and joint space were narrow, and the articular surface fusion was possible in the late stage, but the bone-like perforation-like defect was not as obvious as gout.
2 septic arthritis and traumatic arthritis: traumatic arthritis generally has a history of joint trauma, septic arthritis joint capsule fluid can produce pathogenic bacteria, both blood uric acid is not high, joint synovial fluid examination No urate crystals.
3 Cellulitis around the joints: The soft tissue around the joints is obviously red and swollen, and the systemic symptoms such as chills and fever are prominent, but the joint pain is often not as good as gout, the peripheral white blood cells are obviously increased, and the blood uric acid is normal.
4 pseudo-gout: caused by mineralization of articular cartilage, more common in the elderly with thyroxine replacement therapy, women are more common than men, the knee is the most commonly affected joints. Symptoms of arthritis often have no obvious seasonality, and blood uric acid is normal. Synovial fluid examination can be found in calcium pyrophosphate crystals or apatite. X-ray films can be seen as linear calcification of cartilage, and there can be para-articular calcification. Some patients can have gout at the same time, there is an increase in blood uric acid concentration, and there are two crystals of urate and calcium pyrophosphate in joint synovial fluid.
5 psoriatic arthritis: often involving the distal interphalangeal joints, metacarpophalangeal joints and metatarsophalangeal joints, a few may involve the spine and ankle joints, manifested as asymmetrical arthritis, may have morning stiffness. About 20% of patients may have elevated blood uric acid, sometimes difficult to distinguish from gout. X-ray films showed that joint space widening, bone hyperplasia and destruction can exist at the same time, and the distal end refers to the distal end of the pencil tip or cap.
3. Kidney stones: recurrent kidney stones should be differentiated from multiple stones caused by hyperparathyroidism. The latter has persistent bone pain, pathological fractures and hand and foot spasm. Radionuclide bone scan shows abnormal bone metabolism in the whole body, and the level of parathyroid hormone is significantly elevated, which can be differentiated from gout.
