Gout: diagnosis by laboratory and instrumental methods

What methods for diagnosing gout exist?

With gout diagnosis is often associated with certain difficulties, even for experienced professionals. This is due to the fact that complaints of patients most often relate to pain in the joints. And this can be the result of a variety of diseases.

To increase the likelihood of a true diagnosis, you need to contact the rheumatology department. The specialists of this department have more experience with arthritis than their colleagues.

And they are faster than other doctors will be able to determine gout.

To diagnose a specialist, you must have the results of clinical, laboratory and instrumental examinations.

For some patients, the process of diagnosing is not associated with any difficulties. Others are faced with the fact that they have to take a lot of tests and undergo various examinations.

Everything depends on what caused the development of the disease, and the symptoms of its manifestation.

Diagnosis of gout is divided into several stages:

1. conducting a conversation with a patient;
2. drawing up a clinical picture of the course of the disease;
3. instrumental and laboratory studies.

Carrying out a survey (anamnesis)

The collection of information on the course of the disease is very important for establishing the correct diagnosis. This makes it possible immediately to exclude the presence of other diseases with similar symptoms.

In an interview with a patient, a specialist has the opportunity to find out exactly how the disease began, what symptoms were the first and in what order they were manifested. As a rule, the patient manages to recall the first manifestations of pathology.

Most often these are pains and unpleasant sensations in the small joints of the hands and feet. Large joints are extremely rarely affected at the initial stage.

The conversation also touches on the topic of illnesses suffered by a patient in the past. Of great importance are:

• complex surgical operations;
• kidney disease;
• long-term use of certain medications.

In a conversation with a specialist, a question will be raised about the patient's lifestyle, his nutrition, his propensity for bad habits.

For example, the presence of a large number of meat products in the diet, the use of alcoholic beverages, smoking, exorbitant physical exertion give every reason to assume the development of gout.

Another cause that causes the development of pathology, may be non-compliance with the drinking regime, that is, the use of insufficient amounts of liquid during the day.

Clinical picture of pathology

A clinical picture is the union of all the symptoms of a disease and changes in the patient's condition over time. For an experienced specialist who constantly monitors the patient, accurate diagnosis of gout is possible even without the results of clinical studies.

Assessing the changes in the patient's condition, the doctor is guided by the stage of gout development. Due to regular medical examinations, three main stages of pathology development can be distinguished:

1. hyperuricemia;
2. accumulation of urate in the body;
3. deposition of urate in tissues;
4. acute gouty inflammation.

At the initial stage of the disease, the patient for a long time may not experience any discomfort. But it is with time that it provokes the development of the second stage. In rare cases, gout can manifest itself and without changes in the level of uric acid.

The second stage of the disease can manifest itself as the first symptoms that will force a person to see a doctor. For this stage, urates, small crystals of sodium and potassium salts of uric acid, enter the soft tissues.

The accumulation of a large number of urates leads to the third stage of pathology. They severely injure soft tissues, delivering many unpleasant moments. In addition, the body begins to react painfully to the presence of foreign substances.

Instrumental research

Conducting instrumental studies is mandatory for all patients who seek help with joint pain.

In the early stages of gout, this kind of research provides little information, since changes in the tissue structure are almost not observed.

Despite this, these methods make it possible to exclude the development of other rheumatic pathologies.

Various methods can be used to conduct research:

• Ultrasound;
• CT scan;
• X-ray of the affected joints;
• scintigraphy with technetium pyrophosphate.

The maximum effectiveness of ultrasound will be observed only at the stage of exacerbation.

The onset of an acute attack is characterized by a marked expansion of the joint gap, the formation of edema, and soft tissue around the affected joint.

All these changes become less noticeable within a week after exacerbation. And by the end of the second week there is a high probability that ultrasound examination will not reveal any changes.

Carrying out this type of research with chronic ailment makes it possible to diagnose a small deformation of the joint surface and the dislocation of inflammatory foci. In addition, this method makes it possible to identify accumulations of urate in the kidney and bladder.

The choice of the diagnostic method should be done by a specialist. With pronounced symptoms and typical manifestations of the disease, the instrumental method of diagnosing gout may not be necessary.

Computed tomography is a series of high-precision X-ray images.

This study helps to identify the exact location of the inflammation foci and to determine the degree of deformation of the affected joint in the late stages of gout development.

At an early stage in the period of exacerbation, the images of soft tissue around the diseased joint will be noticeably visible.

Radiography is prescribed in the early stages of the pathology, in order to exclude the presence of other ailments causing inflammation of the joints. With gout, significant transformations are not observed. Only pictures taken at a chronic form of the disease, allow to determine the diagnosis.

Scintigraphy with technetium pyrophosphate is carried out only in those cases when the clinical picture of the disease is uncertain, and it is difficult for the doctor to draw any conclusions.

To conduct research in the blood is introduced a special substance - pyrophosphate technetium. It accumulates in the places of greatest deposition of urate.

Thanks to this, the specialist can determine the location of the pathological process as precisely as possible.

These studies can reveal the accumulation of urate in other places:

1. the spine;
2. in the chest;
3. clavicles.

Laboratory tests of blood and urine

Laboratory tests for gout are able to give a specialist a lot of information about the processes occurring in the body. They make it possible to trace how uric acid is formed and excreted at different levels.

Several times blood and urine tests are performed to be able to assess the changes that have occurred in their composition.

In addition, these tests with gout enable the specialist to distinguish it from other diseases with similar symptoms.

At the time of exacerbation of inflammation may appear leukocytosis, that is, an increased number of leukocytes in the blood. In addition, the activation of the inflammatory process provokes an increase in ESR.

If the patient suffers from a severe kidney pathology or abnormalities in the functioning of the circulatory system, a general blood test may show other changes.

One of the most important studies is a biochemical blood test. It allows you to determine the level of uric acid in the blood and hyperuricemia.

It is the definition of hyperuricemia that is given increased attention, since this indicator is a risk factor for gout.

Determine the level of uric acid you need before starting therapy and after the treatment is started.

Biochemical analysis makes it possible to detect an increase in the level of C-reactive protein, a change in the level sugar, an increase in creatinine, an organic substance formed during the metabolic processes of proteins, and urea. And also the level of lipids, lipoproteins and calcium is determined.

During the analysis, the levels of different enzymes and substances are checked, which allows you to learn how other internal organs work. In addition, it makes it possible to make a more accurate diagnosis of secondary gout.

The analysis makes it possible to determine the presence of blood in the urine, to reveal the albumin fraction of proteins, cells of the cylindrical epithelium.

All these changes can occur after the lesion touches the epithelium of the renal pelvis.

Biochemical analysis of urine is conducted in order to establish the level of uric acid. For the analysis, the daily norm of the substance is taken.

This indicator may vary depending on the causes that caused gout.

If there are no pathological processes in the kidneys and the filtration passes normally, then the uric acid level in the urine goes up parallel with the same value in the blood.

The synovial fluid is also used for the study. To obtain it, puncture the affected joint. The analysis allows to reveal an increase in the content of leukocytes, salts of uric acid. Maximally confirm the diagnosis of gout allows the detection of the urate sodium in the cytoplasm.

Studies are conducted on the content of tofusov - dense subcutaneous formations.

When they are opened, a paste-like mass of white color or even small white crystals can be found.

Diagnosis of gout is hampered by the presence of other rheumatic pathologies, which are accompanied by a similar symptomatology and manifestations. This is about:

• rheumatoid arthritis;
• psoriatic arthritis;
• chondrocalcinosis, which is also called pseudogout.

To facilitate the process of diagnosis, it is necessary to use special criteria for differential diagnosis between these pathologies.

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Methods for diagnosing gout

To establish the diagnosis of gout, the diagnosis is complex. The attending physician prescribes a patient examination. After a complete diagnosis is made, the doctor will also prescribe the treatment.

Methods of examination

Doctors diagnose this ailment without much difficulty based on the results of three basic surveys: physical, laboratory, instrumental.

The physical consists in a visual examination of the patient, identification of complaints, hereditary predisposition to the disease.

It is important to differentiate gout for the presence (exclusion) of factors that can lead to the development of the disease.

For example, concomitant development of arthritis or oncological processes.

The laboratory is to take the patient's tests:

1. urine on% of salt content in urea according to Zimnitsky (daily urine dose is analyzed);
2. biochemistry on the level of uric acid in the blood, with gout the coefficients are exceeded;
3. GFR urine to determine the functionality of the kidneys;
4. A sample from the fluid of the joint to the possible presence of uric acid in it.

Instrumental is carried out additionally if the diagnosis is not established after the 2 first methods. Patients are assigned an X-ray of the skeleton for the presence of tofus in the articular cartilaginous membrane.

Criteria for diagnosis

To formulate the diagnosis was justified, doctors rely on certain symptoms (signs) of the disease.According to the Roman diagnosis, the diagnosis is made with:

• tofusov in blood, uric acid (the level of urea is increased);
• attacks, especially active in acute arthritis.

By the method of the American Association of Rheumatologists, six signs of gout of 12 possible are taken into account. The final diagnosis is made with:

1. monoarthritis;
2. tofus in the blood;
3. unilateral defeat of the arch of the foot or thumb;
4. negative reaction to flora during the study of sowing in the fluid inside the joint;
5. puffiness, redness of the affected joint;
6. asymmetry of the joints on the basis of the performed X-ray of the skeleton;
7. detection of subcortical cysts as a result of studying the radiographic image.

To establish a definitive and correct diagnosis of clinical manifestations of the disease is not enough. Without confirmation of whether or not crystals of sodium monoaurate are present in the urea, the diagnosis can not be considered accurate.

Monourate crystals or tofus content in synovial fluid are detected only when exacerbated.

A definite diagnosis is not made until the crystals in the fluid taken from the inflamed joint are found, regardless of the way they are searched. So, with gout:

• tofu;
• uric acid exceeds the mark of, 2 mmol / l;
• crystals of urate sodium in the synovium;
• manifestations of arthritis attacks clinically during the remission period and last no more than 2 weeks.

Laboratory research

The serum level in uric acid is studied at the exceeded values. Perhaps the development of hyperuricemia, which in turn provokes the development of gout.

However, this is only an assumption. Hyperuricemia is simply absent in some patients. Measure the serum level of acid when the disease worsens incorrectly.

The increase in the level is possible if there is a concomitant pathology, for example, in the kidneys, when uric acid excretion is exceeded there.

Identify a different concomitant gout pathology allows biochemistry, blood serum studies to determine the presence in it of the level of lipids, creatine, enzymes, the percentage of urea.

Changes in joints

With gout, the synovial structure of the joints changes. To study it, the patient takes a puncture. The method consists in taking fluid from the joint cavity, then the liquid is studied under a microscope to establish:

1. density;
2. transparency;
3. colors;
4. viscosity;
5. presence of clots.

The liquid is turbid, yellowish green, the viscosity is lowered, it flows out of the needle with a trickle. The contents of the effusion are filled with erythrocytes, neutrophils, destroyed cells, leukocytes, phagocytes, in the presence of which the inflammatory process is activated in the articular bag.

Determine the degree of inflammation in the joints is possible after the synoviocytogram. Inflammation of neutrophils in the liquid reaches 93%, while lymphocytes are almost absent (no more than 8%).

When the gout goes to a chronic form, the cytogram indices are within the normal range.

In addition, fluoroscopy of the affected joint is performed, which allows to reveal the degree of destruction of bones, the condition of tofus.

A large toe is examined for possible damage to cartilage of bone tissue in it. With fluoroscopy of the fingers, the doctor will see the presence of tofus. For their examination, if necessary, MRI, CT.

Defects are possible in all layers of the bone, the diameter of the joint resting on it reaches 5 mm.

Necessity of diagnostics

Differential diagnosis of gout is necessary to confirm or deny the presence of other concomitant diseases that can provoke its development. This is important for the correct appointment of a doctor for effectiveness. High risk of developing gout with:

• septic arthritis, identifies the crystals of sodium monoaurate in the synovial fluid. If a sepsis is suspected, the patient is placed in purulent surgery;
• rheumatoid, psoriatic or reactive arthritis;
• pyrophosphate arthropathy;
• osteoarthritis, often developing with gout.

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Gout

Now gout suffer 3 people from a thousand, more often men 40-45 years and older, due to heavy physical labor, unbalanced diet and uncontrolled use of alcohol. Women get sick less often, usually in the post-menopausal period.

Gout may also result from improper kidney function or hereditary disease. It is very important to notice the first symptoms and treatment of the disease in time to instruct a competent rheumatologist.

Causes

The main reason why gout develops is hyperuricemia. This condition occurs at a constant elevated concentration of the product of nitrogen metabolism - uric acid.

Factors provoking the onset of the disease:

1. Unbalanced nutrition.
2. Heredity.
3. Bad habits.
4. Violation of the normal functioning of the kidneys.
5. Sedentary lifestyle.
6. Presence of chronic diseases that affect the metabolism (diabetes, hypertension, blood diseases, cardiovascular system and kidneys).
7. Side effects of drugs (after treatment of cancer, with frequent use of diuretics and other drugs).
8. Autoimmune diseases.

Factors that provoke an attack of acute arthritis:

• a sharp violation of diet (for example, a feast);
• starvation;
• stress;
• trauma, bleeding, surgery;
• infection;
• use of medicines;
• heavy physical activity and even long walking.

Classification

In the course of the disease and the nature of the onset, the disease of gout is divided into two types.

Primary- the disease appears as an independent disease as a result of eating disorders, improper and sedentary lifestyle, genetic predisposition.

Secondary- the disease is a manifestation or complication of other diseases and is caused by medication, the presence of chronic pathologies, a violation of metabolic processes.

According to the pathogenesis of gout, its forms are distinguished:

Renal. With this form, excretion (excretion) of uric acid is sharply reduced.

Metabolic. Synthesis (formation) of uric acid is significantly increased.

Mixed. There is excessive synthesis of uric acid and significantly reduced its excretion from the body.

According to clinical manifestations:

Premorbid period. It is asymptomatic, only at the examination it can be revealed by hyper-hyperemia.

Intermittent period. Alternation of exacerbations of arthritis with asymptomatic course.

Chronic gout. Deposits of uric acid crystals form gouty tofusi (nodular densities and growths), frequent attacks of gout.

In the course of the disease:

Light form: seizures occur 1-2 times a year, no more, affects up to two joints, tofusi insignificant, small or nonexistent.

Medium shape: the frequency of acute attacks increases to 3-5 times per year, affects from 2 to 4 joints, the presence of multiple small tofus and urolithiasis.

Heavy Form: seizures are frequent and painful, lesions of many joints, presence of multiple tofusi of different sizes, pronounced nephropathy.

Symptoms

Symptoms of gout depend on the period of this disease. At the very beginning the disease does not make itself felt, there are no signs, except for the increased content of urates in the blood.

The premorbid (latent) period is asymptomatic and does not appear clinically. It can be identified only with the help of a blood test for urate content.

But since patients in this period do not go to the doctor, the disease passes into the intermittent period, in which there are acute recurrent manifestations of gout.

The main symptom of gout is acute arthritis. In this case, any joints are affected, but often the first metatarsophalangeal foot joint suffers. Brushes, elbows, ankles and femoral joints are also affected. At the same time, one or more joints can become inflamed.

The main symptoms of an acute attack of gout:

1. The disease begins suddenly, more often at night.
2. There is a sharp, shooting pain in the joint, hyperemia and hyperthermia.
3. Inflammation, puffiness, the skin at the joint site is stretched, has a glossy surface and a purple-violet hue.
4. In severe cases, an attack of arthritis is accompanied by fever, chills, severe pain with little movement or light contact with the laundry.
5. During the day the pain subsides, but at night they resume.
6. The attack lasts 5-6 days, gradually calms down.

After treatment, the joint returns to its original state after 7-10 days. Then comes the interictal period.

The patient has no complaints, but if he does not receive appropriate treatment, seizures become more frequent, become more severe and painful, the interictal period is shortened, develops chronic gout.

Signs of chronic gout:

• Formation of nodules (tofusov).
• Deformation of the joints, reduction of their mobility or complete immobility.
• Atrophy of muscles around the affected joint.
• Increased seizures.
• Involvement in the pathological process more joint articulations.
• Ulceration of the skin above the tofus, poor healing.

In severe disease there is gouty status. This is a complication in which there is a massive release of uric acid into the blood.

The patient is worried about the constant pain and swelling of the tissues around the inflamed joints.

DIAGNOSTICS

Diagnosis of gout does not cause difficulties for experienced rheumatologist, but sometimes it can be confused with other rheumatic diseases due to the similarity of symptoms. Gout has atypical forms, which should also be taken into account.

The main methods of gout diagnosis:

Laboratoryincludes clinical analysis of urine and blood, Zemnitsky and Reberg samples, blood biochemistry, analysis of synovial fluid with a polarizing microscope.

Instrumentalmethods are represented by arthrocentesis (joint puncture and synovial fluid intake), tofus biopsy with the study of their contents.

Hardware- this is radiography, ultrasound of joints, MRI or CT (computed tomography).

In modern medicine, the criteria for the "Roman" classification of the disease or the criteria proposed by the American Association of Rheumatologists are used to diagnose gout.

Roman criteria:

1. Presence of gouty nodes (tofusov).
2. Hyperuricemia.
3. In the tissues and synovial fluid there are urates.
4. In the anamnesis there is an attack of acute arthritis.

The diagnosis is confirmed if two or more of the listed points coincide.

Criteria for the American Rheumatology Association:

• In the anamnesis there were attacks of arthritis.
• Hyperureukia.
• Presence of tophi.
• The peak of inflammation manifests itself in the first day of the disease.
• Monoarticular (one joint is affected) arthritis.
• Asymmetry of the patient joint.
• In the area of ​​inflammation, there is pronounced hyperemia.
• One-sided lesion of the first metatarsophalangeal joint.
• Continuing pain and swelling.
• One-sided defeat of the arches of the arch of the foot.
• Absence of microflora in the synovial fluid.
• On the roentgenogram, subcortical cysts are visible.

The diagnosis of gout is confirmed if there are six criteria from the above.

TREATMENT

Gout therapy is very long and is undergoing remission. Patients take drugs for years, taking some breaks. For the treatment of gout, it is very important to follow a certain diet, maintaining a daily diuresis at the desired level (about 2 liters).

Compliance with diet and restriction of alcohol intake gives good results. It is unacceptable to starve or overeating, and when overweight the patient is recommended a low-calorie diet.

But in any case, not starvation! It can provoke an attack due to a sharp increase in the concentration of uric acid in the body.

It is also important to use a sufficient amount of liquid (2 liter per day).

The main task of treating gout is to reduce the concentration of urates.

It can be achieved in three ways: by taking uricosuretics (drugs that increase the excretion of uric acid), the use of uricodepressors (drugs that suppress the synthesis of uric acid) and limiting the intake of purines with food. To treat gout after the first signs are manifested immediately, not allowing the transition of the disease into a chronic form.

The basic principles of complex treatment of gout:

1. Reduction of purine compounds in the body.
2. Treatment of acute attacks.
3. Treatment of chronic manifestations.
4. Treatment of concomitant diseases and complications.
5. Physiotherapy
6. Dietotherapy.

A severe course of gout, ineffective treatment, multiple formation of tofus, ulcers, their infection, deformities of the joints - these are indications for surgical intervention.

With an acute attack of gouty arthritis, treatment is aimed at alleviating the condition of the patient.

The main measures for an acute attack of gout:

• Provide the patient peace and the most comfortable position. It is better to give the sick limb an elevated position, apply cold and, if possible, immobilize. Cover it is not necessary, because any, even light, touch of the sheet causes sharp, severe pain.
• Abundant alkaline drink. During an exacerbation it is recommended to drink up to 3 liters of liquid per day.
• Compliance with diet.
• Of the medications used painkillers, non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids. Local application of ointments or gels that facilitate the condition, with anti-inflammatory and analgesic effect.
• When the condition improves, physiotherapy is shown: electrophoresis, UV of the affected joint, UHF.

COMPLICATIONS

If non-adherence to preventive measures, improper treatment or lack thereof, gouty inflammation can be devastating to the body as a whole.

There is such a thing as a gouty kidney - a state of kidney dysfunction due to violation of purine metabolism, which leads to chronic renal failure and urolithic disease. Renal failure often causes the disruption of the cardiovascular system, the development of coronary heart disease, hypertension and diabetes.

Also, gout leads to the development of pathology of the musculoskeletal system (polyarthritis, osteoporosis), the formation of tofus, which cause deformation of the joints and their functional disturbance or immobilization.

PREVENTION

In chronic gout, preventive measures should be taken to avoid frequent seizures.

Main preventive measures:

1. healthy diet, constant adherence to a special diet;
2. exclusion of alcohol;
3. regular exercise;
4. the prevention of obesity and the fight against obesity;
5. drinking enough fluids;
6. possibly limiting the use of medicines;
7. wearing comfortable shoes;
8. periodic sanatorium treatment;
9. physiotherapy;
10. regular visits to a doctor, examination at least once a year.

Observing preventive measures, paying attention to the first signs and treatment of gout entrusting professionals, you can avoid frequent attacks of the disease and its terrible complications.

Prognosis for recovery

Unfortunately, modern medicine can not completely cure gout, but with adequate timely treatment and compliance with preventive measures can reduce the frequency of seizures and significantly increase the period remission.

But in view of the fact that gout can lead to a number of complications with aggravation, the disease can lead to disability and loss of efficiency.

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Diagnosis of gout

• Anamnesis contains more than one attack of arthritis;
• In the first 24 hours of an acute attack, the inflammation of the joint reaches its maximum;
• Slight puffiness and unpleasant sensations (more often painful) in the first phalanx of metatarsophalangeal joints;
• The defeat of the first phalanx of metatarsophalangeal joints of one leg;
• Lesions of joints of one foot;
• Theoretical assumption of the presence of tofus formations;
• The presence of diagnosed hyperuricemia;
• Unbalanced swelling of the joints;
• Indication on the X-ray of the formation of a subcortical cyst in the absence of erosion;
• Sowing synovial fluid gave negative results.

The reliability of the diagnosis is unambiguous in the presence of classification criteria A or B. According to the generally accepted agreement, gout is diagnosed with six of the 12 points of classification criterion B.

Rational approaches to the diagnosis of gout. EULAR Recommendations
At first glance, the diagnosis of acute gouty arthritis is easily accomplished without microscopy.

Rapid (less than a day) peak of inflammation, acute pain, involvement of metatarsophalangeal joints, asymmetry of edema, but many of these clinical signs are also characteristic of other diseases.

For example,Behcet's disease, sarcoidosis, synovioma and similar inflammatory processes of various etiologies.

In connection with the foregoing, the EULAR expert advice recommends that you make an accurate diagnosis puncturing joints if any arthritis is suspected, in whose differentiation there is even the slightest doubt. Modern equipment of most clinics' laboratories.

has a rheumatological department, allows to carry out the whole complex of diagnostic studies.

Therefore, the representatives of the European Antirheumatic League recommend using the hospitals available in the arsenal means and laboratory instruments, as well as the skills and experience of specialists with a view to a rational approach to diagnosis gouty arthritis.

The need to identify the problem and focus on the methods of diagnosis is caused by a rapid increase in the number of gout sufferers in developed countries. And if earlier only men were ill with her, now cases of illness in women are increasingly being revealed.

With all that is available in the luggage of knowledge from clinicians, and the possibility of using modern methods laboratory diagnosis, most of the diagnoses are established only in the eighth year of the current disease.

Therefore, it is so important to focus the attention of first-level doctors and rheumatologists in clinics on a full study, taking into account all the data obtained both during clinical examination and in carrying out all necessary surveys.

Instrumental methods for diagnosing gout

Puncture of the joints. Puncture is performed to obtain synovial fluid. In the absence of any obvious symptoms, when there is only a slight inflammation of the joints, the presence of synovial fluid is already greater than in the standard norm.

Considering that only one drop is sufficient for research, this method of diagnostics is very important.

The presence of hyperuricemia.

The diagnosis of hyperuricemia itself is not accompanied by mandatory gout, but gout necessarily develops against the background of increased uric acid in the blood. Therefore, the faster the progression of hyperuricemia, the higher the risk of gout.

Given these facts, overdiagnosis, as a single method of confirming the diagnosis, is unacceptable. Erroneous diagnosis leads to a loss of time, which is dangerous for the patient, since gout can lead to early disability.

X-ray. Late gout is often characterized by the symptom of a "piercer which is a bone defect, clearly visible on an X-ray. Unfortunately, this type of diagnosis is only suitable for cases of recurrent gouty arthritis in the late stages (from eight years onwards). As a rule, the disease, lasting 2-4 years, has no visible bone defects.

Ultrasound of joints. A new experimental direction in the diagnosis of gouty arthritis. Ultrasound research is widely recognized as one of the most advanced and most promising. An indication of the presence of the disease is the "double contour visible on the screen when performing ultrasound joints.

This phenomenon occurs due to the ability of urates to localize on the cartilage of the joint, which forms a light line parallel to the line of bone transfer into the cartilage. In addition, ultrasound of the joints exhibits tofus well, and this is a clear sign of gout. Thus, performing an ultrasound examination of the joints can help to identify the early stage of the disease and helps to take emergency therapeutic measures to stop the attack and treat the disease at an early stage occurrence.

MRI.Magnitno-resonant tomography is spent, basically, for definition of tofuses and is an informative material at differentiation of the diagnosis. Similarly, computed tomography (CT), which more accurately identifies the accumulation of urates in tofusnye masses.

To determine purulent gout with suspicion of tofus formation, experts of the European anti-rheumatic league recommend to sow synovial fluid and stain Gram to exclude a medical error that could cause serious harm patient.

conclusions

As the in-depth studies of the EULAR expert group showed, first-line doctors (clinicians, physicians in polyclinics) do not always use even 50% of the above comprehensive survey. It is this factor that influences the late diagnosis of gout. Experts recommend doctors to treat the definition of the disease more carefully and responsibly, since there are practically no difficulties in diagnosing the disease.

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Research methods for rheumatic diseases

Various diagnostic methods are used to diagnose rheumatic diseases, among which laboratory and instrumental research is the most important.

Physical examination

Patient interview

The main symptom of rheumatic diseases is pain in the joints, caused by the pathological process in the joints and periarticular tissues.

The onset of pain is often associated with physical overload of the joint, stretching of its tendon-ligament apparatus, irritation synovium osteophytes, microcirculatory disorders, changing meteorological conditions and metabolic disturbances in bones of the joint.

The pains are often emotional, leading to the development of depression and psychogenic arthropathies, in which there are no organic changes in the joints, even with years of observation.

Diagnostic value is the nature, duration, intensity and time of occurrence of pain.

So, with rheumatoid arthritis, the pains are aching, intensifying in the second half of the night and decreasing after the onset of movement.

Characteristic is the feeling of stiffness in the joints in the morning.

Deforming osteoarthritis is accompanied by blunt, aching pains that increase by the end of the day after exercise and in the first half of the night.

Pain decreases by morning and at rest. Often, patients complain of muscle weakness in the areas adjacent to the affected joints.

Anamnesis

A carefully collected history is important.

1. It is necessary to establish the onset, course and duration of the disease. Gout and infectious arthritis develop suddenly, and rheumatoid arthritis and deforming osteoarthritis gradually. In the course of the disease, joint damage can be recurrent (with gout) migrating (with rheumatism and viral arthritis), continuously progressive (with rheumatoid arthritis, Reiter's syndrome) and chronic (with deforming osteoarthritis).
2. Joint damage can be acute (less than 6 weeks) and chronic (more than 6 weeks).
3. Rheumatic diseases can occur with the defeat of one (monoarthritis), two or three (oligoarthritis) and more than three joints (polyarthritis).
4. It should be clarified whether the patient or his family has had any infections (nasopharyngeal, intestinal, urogenital) shortly before the onset of the symptoms of the lesion, to identify the adverse effects of the external environment (cooling, insolation, injury).

Inspection of the patient

The condition of patients can be satisfactory, of moderate severity and severe.

When examined, the swelling of the joints is revealed, due to the inflammatory edema of the synovial membrane and the soft tissues surrounding the joint, and sometimes to the joint cavity.

With chronic arthritis, defoguration (change in shape) of joints develops due to hypertrophy of the synovial membrane and fibrotic sclerotic processes in the periarticular tissue.

It is possible to detect deformation of the joints - a persistent change in the shape of the joints due to bone growths. The swelling of the joint should be distinguished from the swelling of the periarticular tissues.

A sign of inflammation may be an increase in skin temperature over the joint. Hyperthermia is usually accompanied by a discoloration of the skin. So, bright red skin color is characteristic for arthritis of the big toe in patients with gout, crimson-red for psoriatic arthritis.

Mandatory in the physical examination is the determination of the volume of motion of each affected joint.

Determine the volume of active and passive movements in all directions (flexion, extension, withdrawal, reduction, supination and pronation).

Restriction of movement can be associated with pain and effusion, the development of fibrotic and bone ankylosis, mainly in the chronic course of the disease.

When moving in the joints, clicks may occur, the source of which may be intraarticular formations or tendons. For example, friction between the femur and the tibia may be accompanied by clicks in the knee joint.

Pathological changes in the joints are often accompanied by a lesion of the muscles adjacent to them, in which inflammatory and granulomatous changes develop, vasculitis and degenerative-dystrophic processes.

Clinically, muscle damage is manifested by weakness and atrophy, but they are usually not the main symptoms of the disease.

The only rheumatic disease in which muscle damage determines the clinical picture is dermatomyositis.

Rheumatic diseases are accompanied by a variety of skin lesions.

Erythema in the form of a butterfly in the region of the back of the nose is revealed in systemic lupus erythematosus; multimorphic exudative erythema, rounded pinkish-red spots or papules at the rear of the hands and feet with Stevens-Johnson syndrome and dermatomyositis.

A characteristic symptom are nodes of different size and density, located in the deep layers of the skin and subcutaneous tissue. For example, in rheumatoid arthritis, nodules are found in the region of olecranone.

Gouty nodes, deposits of monosodium urate crystals - in the tendons, cartilages, synovial membranes of the joints.

The most frequent localization is the ears, the area of ​​the elbows, knee joints, fingers and feet.

At inspection the condition of the musculoskeletal system is studied both in statics and dynamics.

It is necessary to establish pathological deviations of the gait - lameness, uneven step length, movement with preferential support on the heels, walking on straight legs due to the impossibility of flexion-extensor movements in knee joints. It should be established the ability of the patient to climb and descend the stairs.

Laboratory methods of research

The standard examination includes a general blood test, the study of ESR and C-reactive protein. The increase in ESR and the appearance of C-reactive protein occurs in infectious and autoimmune diseases, arthritis, in pregnant and elderly people.

The determination of rheumatoid factor, antinuclear antibodies, complement and titer of antibodies to streptolysin-O is not have a diagnostic value with minimal or nonspecific lesions of the joints and connective tissue. Conducting these serological examinations is indicated only with severe symptoms of the corresponding diseases.

The high titer of antinuclear antibodies and their immunofluorescent staining have a diagnostic significance. The presence of antibodies to native DNA is confirmed by edge (peripheral) luminescence, which is characteristic of systemic lupus erythematosus.

In acute and chronic monoarthritis, swelling in the joint after trauma and suspected infectious, crystalline arthritis or hemarthrosis, joint puncture and synovial fluid aspiration are performed.

Assess the overall appearance and viscosity of the synovial fluid, count the number of leukocytes in it, stain Gram, carry out sowing according to indications and determine sensitivity to antibiotics. The presence of crystals is determined by polarization microscopy.

• With non-inflammatory joint damage, the synovial fluid is clear, amber, viscous (a drop released from the syringe is drawn into a long thread), the number of white blood cells is less than 2000 μl-1.
• In inflammatory lesions, the synovial fluid is opaque, yellow, the viscosity is reduced (there are no threads after the drop), the number of leukocytes exceeds 2000 μl -1, neutrophils predominate.
• With hemarthrosis, the synovial fluid has a hemorrhagic character.
• With purulent arthritis, the synovial fluid is dense, cloudy, with a lower viscosity, the number of leukocytes exceeds 5, 00 μl -1, neutrophils predominate. The synovial fluid is stained by Gram and seeded.
• Crystals of urate sodium in synovial fluid with gout are needle, long, with negative birefringence; crystals of calcium pyrophosphate dihydrate under pseudogout are short, diamond-shaped, with positive birefringence.

Instrumental diagnostic methods

X-ray examination is of great importance in the diagnosis, assessment of the severity of joint damage and subsequent dynamics of the process.

Early radiologic signs of the majority of chronic arthritis are a thickening of soft tissues or periarticular osteoporosis.

With the progression of the disease calcification of soft tissues, cartilage, bones, constriction and irregularity of joint cracks, erosion, cysts of the subchondrial bone, osteosclerosis, osteophytes, bone ankylosis. Further examination with a detailed and correct analysis of the results of X-ray examination is usually not required.

Ultrasound (ultrasound) has limited indications for use. The method is used to detect soft tissue damage, synovial cysts and tendon injuries.

Scintigraphy is a sensitive but not enough specific method for diagnosing inflammatory and metabolic lesions of bones and periarticular soft tissues, which sometimes prevents these defeat. 99mTc, leukocytes labeled with 111In, and 67Ga are used.

Computed tomography (CT) is an effective diagnostic method that allows you to obtain images of sagittal, frontal and horizontal sections of all joints. CT allows us to identify sarcoiliitis, osteoid-osteolysis, articular mice, osteomyelitis and osteonecrosis.

Magnetic resonance imaging (MRI) has a high resolving power and is superior to X-ray and CT in the diagnosis of intraarticular disorders, soft tissue injuries, subluxations or arthritis of the intervertebral joints.

Carry out this study only in selected cases, when simpler and cheaper methods do not provide sufficient information.

A source: http://medicoterapia.ru/metodi-issledovaniya-pri-revmaticheskih-zabolevaniyah.html