Gout pathophysiology

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

Overview

Gout occurs when mono-sodium urate crystals form on the articular cartilage of joints, on tendons, and in the surrounding tissues. Purine metabolism gives rise to uric acid, which is normally excreted in the urine. Defects in the kidney may cause uric acid to build up in the blood, leading to hyperuricemia, and the subsequent formation of gout crystals.

Pathophysiology

Gout occurs when mono-sodium urate crystals form on the articular cartilage of joints, on tendons, and in the surrounding tissues. Purine metabolism gives rise to uric acid, which is normally excreted in the urine. Uric acid is more likely to form into crystals when there is a hyperuricaemia, although it is 10 times more common without clinical gout than with it[1]

Purines can be generated by the body via breakdown of cells in normal cellular turnover, or can be ingested in purine-rich foods such as seafood. The kidneys are responsible for approximately one-third of uric acid excretion, with the gut responsible for the rest. It may be possible that defects in the kidney that may be genetically determined are responsible for the predisposition of individuals for developing gout.

Hyperuricemia is considered an aspect of metabolic syndrome, although its prominence has been reduced in recent classifications. This explains the increased prevalence of gout among obese individuals.

Typically, persons with gout are obese, predisposed to diabetes and hypertension, and at higher risk of heart disease. Gout is more common in affluent societies due to a diet rich in proteins, fat, and alcohol.[2] It is known that lead sugar was used to sweeten wine, and that chronic lead poisoning is a cause of gout,[3][4] which condition is then known as saturnine gout, because of its association with alcohol and excess.[5]

Gross Pathology

Kidney: Uric Acid Deposition: Gross, an excellent example of gouty nephropathy with deposits and excavation in pyramids
Kidney: Papillary Necrosis: Gross, yellow foci in pyramids, a gout kidney
Bone, synovium: Gout: Gross natural color opened joint with extensive white deposits of uric acid
Bone, synovium: Gout: Gross natural color close-up of extensive uric acid deposits
Kidney: Gout: Gross natural color close-up view of uric acid deposit in medullary pyramid
Kidney: Uric Acid Deposition: Gross natural color close-up and excellent view of opaque material in medullary pyramid of adult kidney


Bone, synovium: Gout: Gross natural color section through sternum and clavicle showing very well uric acid deposits in the periarticular tissue
Urinary Tract: Staghorn calculi in renal pelvis, Gout
Gout; Bursa of Knee


Kidney: Uric Acid Deposition: Gross, infant kidney with excellent uric acid streaks
Kidney: Uric Acid Deposition: Gross good example uric acid streaks in medulla (very ischemic kidney)
Kidney: Uric Acid Nephropathy: Gross, natural color, an excellent view of hydronephrosis with inflamed pelvis and multiple calculi with deposits in medullary pyramids
Kidney: Uric Acid Infarcts: Gross natural color opened kidney showing marked ischemia with dark red medullary pyramids which contrast sharply with the uric acid deposits
Kidney: Uric Acid Infarcts: Gross natural color typical lesion well shown
Kidney: Uric Acid In Medulla: Gross natural color cut surface of kidney uric acid easily seen
Kidney: Uric Acid Infarcts: Gross natural color close-up outstanding photo of the uric acid streaks in medullary pyramids
Knee Joint: Gout. Heavy Deposition of Urate Crystals in Articular Cartilage

Microscopic Pathology

Gout (Needles, no birefringence, monosodium urate)
Skin: Tophus: Micro med mag H&E uric acid deposits with giant cells. Easily recognizable as gout or uric acid tophus
Skin: Tophus: Micro med mag H&E easily recognized uric acid deposit lesion from elbow
Bones-Joints: Gout
Bones-Joints: Gout
Bones-Joints: Gout
Bones-Joints: Gout
Bones-Joints: Gout
Bones-Joints: Gout
Bones-Joints: Gout
Bones-Joints: Gout
Bones-Joints: Gout
Bones-Joints: Gout
Bones-Joints: Gout, alcohol fixed tissues, monosodium urate crystals
Bones-Joints: Gout, alcohol fixed tissues, monosodium urate crystals
Bones-Joints: Gout, alcohol fixed tissues, monosodium urate crystals
Bones-Joints: Gout
Bones-Joints: Gout
Joint: Gout
Joint: Uric Acid Crystals in Acute Gout

Sources

Copyleft images obtained courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA) Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology

References

  1. Virsaladze D, Tetradze L, Djavashvili L, Esakia N, Tananashvili D. (2007). "Levels of uric Acid in serum in patients with metabolic syndrome.". Georgian Med News 146: 34–7. PMID 17595458.
  2. Robert S. Ivker, D.O. , et al (1999). The Complete Self-Care guide to Holistic Medicine, 186–8. ISBN0-87477-986-J. 
  3. Lin JL, Huang PT. (1994). "Body lead stores and urate excretion in men with chronic renal disease". J Rheumatol 21 (4): 705–9. PMID 8035397.
  4. Shadick NA, Kim R, Weiss S, Liang MH, Sparrow D, Hu H. (2000). "Effect of low level lead exposure on hyperuricemia and gout among middle aged and elderly men: the Normative Aging Study". J Rheumatol 27 (7): 1708–12. PMID 10914856.
  5. Ball GV. (1971). "Two epidemics of gout". Bull Hist Med 45 (5): 401–8. PMID 4947583.

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