Case 5: John Crystal Official Learning Objectives

1. Describe nucleotide nomenclature and recognize the major

purine and pyrimidine bases.
Nucleotide- nitrogenous base, pentose monosaccharide,
1-3 phosphate groups
o Nucleoside + phosphate group = nucleotide (aka
nucleoside 5-phosphate or 5-
(ribo/deoxyribo)nucleotide)
1st phosphate group attached by an ester
linkage to 5 OH of pentose = nucleoside
monophosphate
2nd phosphate group = nucleoside
diphosphate/triphosphate
phosphate group connected to
nucleotide by high-energy bond
Nucleoside = pentose sugar + base
o If sugar is ribose = ribonucleoside
A = adenosine, G =
guanosine, C = cytidine, T
= thymidine
o If sugar is 2-deoxyribose =
deoxyribonucleoside
A = deoxy-adenosine, G =
deoxy-guanosine, C =
deoxy-cytidine, T = deoxy-
thymidine

2. Discuss the strategy, regulation, and

components of the purine nucleotide biosynthetic
pathways.
De Novo purine synthesis
o Purine ring constructed in liver by
reactions that add donated C and N
to preformed ribose 5-phosphate
o PRPP- activated pentose (ribose)
that participates in salvage of
purines and pyrimidines
Activated by inorganic
phosphate and inhibited by
purine nucleotides (end-
product inhibition)
Ribonucleotides are end
products of de novo purine
synthesis when
deoxyribonucleotide is required, ribose sugar moiety is
reduced
o Synthesis of 5-phosphoribosylamine from PRPP and glutamine
 Committed step in purine nucleotide biosynthesis
Reaction rate controlled by intracellular concentration of PRPP
Enzyme inhibited by AMP and GMP (end product inhibition)
o Synthesis of IMP (base = hypoxanthine) requires ATP for energy
Requires N-formyl THF donors
o Conversion of IMP to AMP and GMP
Synthesis of AMP requires GTP as energy source
Synthesis of GMP requires ATP
First reaction in each pathway inhibited by the end product of that pathway
o Conversion of nucleoside monophosphates to nucleoside disphosphates and
triphosphates
Nucleoside monophosphate nucleoside diphosphate (via nucleoside
monophosphate kinases, phosphate provided by ATP)
Nucleoside diphosphate nucleoside triphosphate (via nucleoside diphosphate
kinase)

3. List the two enzymes that salvage purines, APRT and HGPRT, and explain their substrate
specificities and regulation.
Salvage pathway for purines
o Due to normal turnover of the cells
nucleic acids or small amount from diet
and converted to NTP and used by body
o Conversion of purine base to
nucleotides irreversible reactions due to
release of pyrophosphate and PRPP is the
source of the ribose-5P group
end-product inhibition of APRT (specific for
adenine) and HGPRT (specific for hypoxanthine
and guanine)

4. Describe the pathways of purine degradation (see

sheet for more)
Occurs in the small intestine nucleic acids
nucleotides (via pancreatic enzymes)
Inside the intestinal mucosal cells, purine nucleotides sequentially degraded by specific enzymes
to nucleosides and free bases with uric acid as end product
Uric acid made in liver and intestines takes place in cytosol, not mitochondria
Dietary purines almost all degraded to uric acid in the body and not used into incorporation into
nucleic acids
o This is why increase in dietary purines (ex: steak, beer) leads to increase in uric acid (due
to increased absorption of urate) and recurrence of gout
Small intestines where DNA broken down to nucleotides via pancreatic enzymes; intestinal
mucosal cells where nucleotides broken down to nucleosides, free bases, uric acid

5. Describe the consequences of hyperuricemia in causing gout.

Gout high levels of uric acid (end product of purine catabolism) in blood = hyperuricemia
deposition of monosodium urate crystals in joints and inflammatory response to crystals
 acute chronic gouty arthritis (possible uric acid stones in kidney can be seen, which can cause
kidney disease block ureters!)
Crystallization most commonly occurs in metatarsophalangeal joint of big toe due to ideal
conditions relatively low temperatures, low pH
o Triggers immune response that leads to inflammation and recruitment of PMNs large
edema and erythema
Hyperuricemia can be caused by overproduction or underexcretion of uric acid
Definitive Diagnosis of Gout aspiration and examination of synovial fluid from affected joint
o Acute gout is characterized by the presence of intracellular monosodium urate crystals
in synovial fluid obtained from joints or bursas visualized by direct examination of a
sample of fluid for crystals using polarized light microscopy
Onset more often at night- acute gout attacks most frequent overnight and in early morning

6. List the agents used to treat gout and explain the mechanism of action of each.
Short term treatment (symptoms): Colchicine and Indomethacin
o Anti-inflammatory, short term strategy
o Indomethacin is a NSAID, but not colchicine. NSAIDs can cause peptic ulcers (one of
main causes of peptic ulcers, other reason is H. Pylori infection usually of the pyloric
antrum)
o Colchicine prevents the formation of microtubules, decreasing the movement of
neutrophils to the affected area. No effect on uric acid levels (like giving propranolol for
hyperthyroidismbeta blockers just alleviate the hypertension and tremors)
o Inhibits the phagocytosis of uric acid crystals by leukocytes. Sharp edges of uric acid
crystals perforate the leukocytes, spilling contents, creating inflammation.

Long term therapeutic strategies: Uricosuric Agents and Uric Acid Synthesis Inhibitors
o Goal: Lower the uric acid level below saturation point to prevent urate crystal
deposition.
o Uricosuric agents (probenecid and sulfinpyrazone) increase renal excretion of uric acid,
used in patients who are underexcretors of uric acid
o Allopurinol- structural analog of hypoxanthine inhibits uric acid synthesis
Used in patients who are overproducers of uric acid
Allopurinol oxypurinol | inhibits xanthine oxidase (XO) accumulation of
hypoxanthine and xanthine (more soluble than uric acid and less likely to initiate
inflammatory response)
In patients with normal levels of HGPRT, hypoxanthine can be salvaged
and reduce levels of PRPP and de novo synthesis
More long-term strategies:
o Control body weight, low-purine diet, increase liquid intake, limit ethanol use, decrease
use of fructose-containing foods and beverages, avoid diuretics.
o Diet rich in low-fat, high protein decreases risk
o Increasing alcohol consumption and diet rich in meat and seafood increases risk