Furunculosis of the nasal vestibule: causes, diagnosis, complications, treatment

This is an approach to diagnosis and treatment of Gout , in which we are going to discuss the investigations, differential diagnosis and treatment of the disease .

Investigations to diagnose Gout 

- Serum uric acid > 7 mg/dl in males
                   or > 6 mg/dl in females
            (it may be normal)
Normal level is
3.5 - 7 mg/dl in males
2.5-6 mg/dl in females
• ESR +++
• TLC +++
• Aspiration of tophi : urate crystals (by polarized microscope).
• Uric acid in urine > 1100 mg / 24 hours = overexcertion.
Normal serum uric acid does not exclude the diagnosis of gout.
- Joint X-ray

•In early disease -7 Normal, but narrowing of joint space with sclerosis may develop with time.
• Gouty erosions (bony tophi) occurring as para articular punched out defects with well defined borders.
• Tophi: eccentric soft tissue swellings.

Differential diagnosis of Gout 

- Rheumatic arthritis.
- Septic arthritis
- TB arthritis.
- Rheumatoid disease.
- Tendonitis.
- Osteoarthritis
Hyperuricemia is frequently associat§d with obesity, hypertension, D.M, hyperlipidemia (syndrome x) but still there is no relation between ++ uric add and hypertension, DM or atherogenesis.

Treatment of Gout

I. Asymptomatic hyperuricemia.

• There is controversy.

• 20 % of patients with asymptomatic hyperuricemia develop arthritis.

• So no treatment except with :

                                     - Family history of renal stone.

                                     - Urinary excretion> 1100 mg / day.

                                     - Serum uric acid> 11 mg/dl.

• It is treated by allopurinol (See below).

II. Acute gouty arthritis

A. NSAIDs in large dose.

• Indomethacine 75mg immediately, then 50 mg 6-8 hourly

• Diclofenac 75-100 mg immediately then 50 mq 6-8 hourly

• After improvement (24-48) hours, use low dose for one week.

• In patients with renal impairment orwith history of peptic ulcer, it is better to use colchicines or steroids.

B. Colchicine 1 mg immediately then 0.5 mg/6 hour, it can be used in patients with gastritis

C. Short term corticosterolds can be used e.g predisolone 30mg/day

with tapering within 7 days, 1Mmethyl prednisolone can be used.

III. Long term management

By hypouricemic drug to keep uric acid < 7 mg % 

Prolonged hypouricaemic drug treatment is indicated for :

- Recurrent attacks of acute gout.

- Tophi

- Evidence of joint damage.

- Associated renal disease.

• Allopurinol (zyloric )

 300 mg / day, lower doses (1OOmg/day) should be used in older patients or if renal function is impaired.

• It inhibits xanthine oxidase enzyme.

• Side effects - l' liver enzyme - Acute gouty arthritis.

- Diarrhea - B.M depression

- Allpurinol hypersensitivity syndrome (skin rash, eosinophilia, hepatic necrosis and renal failure).

• Uricosuric drugs can achieve equivalent reduction in serum uric acid to allopurinol .These drugs should be taken with alkalinization of urine + plenty of fluid .

e.g Probencid ( 0.5-1 gm/12h) or Sulfinpyrazone ( 100mg/8h) .

IV. Gouty kidney

• Plenty fluids.

• Alkaline urine by sodium citrate.

• Allopurinol.

Recommended Diet in Gout 

(this can reduce serum urate by 15%)

• There is no need for severe dietary restrictions but excessive purine intake and alcohol should be avoided.

• Weight reduction, Severe caloric restriction must be

avoided as ++ lactic acid ++ uric acid.

Excessive meat intake ==> ++ risk of gout, but vegetable protein decreases risk of gout.

Important articles to understand Gout :

- Clinical presentations of Gout (Hyperuricemia manifestations)

- Classification of hyperuricemia (Gout)