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Key Features

Essentials of Diagnosis

  • Acute, monarticular arthritis, often of the first metatarsophalangeal (MTP) joint; recurrence is common

  • Polyarticular involvement more common with long-standing disease

  • Hyperuricemia in most; identification of urate crystals in joint fluid or tophi is diagnostic

  • Dramatic therapeutic response to nonsteroidal anti-inflammatory drugs

General Considerations

  • A metabolic disease of heterogeneous nature, often familial, associated with abnormal deposits of urate in the tissues and characterized initially by a recurring acute arthritis, usually monarticular, and later by chronic deforming arthritis

  • Secondary gout is from acquired causes of hyperuricemia

    • Medication use (diuretics, low-dose aspirin, cyclosporine, and niacin)

    • Myeloproliferative disorders, multiple myeloma, hemoglobinopathies

    • Chronic kidney disease

    • Hypothyroidism, psoriasis, sarcoidosis, and lead poisoning

  • Alcohol ingestion promotes hyperuricemia by increasing urate production and decreasing the renal excretion of uric acid

  • Hospitalized patients frequently suffer attacks of gout because of changes in

    • Diet (eg, inability to take oral feedings following abdominal surgery) or

    • Medications that lead either to rapid reductions or increases in the serum urate level

Demographics

  • Especially common in Pacific Islanders, eg, Filipinos and Samoans

  • 90% of patients with primary gout are men, usually over 30 years of age

  • In women, the onset is typically postmenopausal

Clinical Findings

Symptoms and Signs

  • Sudden onset of arthritis

    • Frequently nocturnal

    • Either without apparent precipitating cause or following rapid fluctuations in serum urate levels

    • The MTP joint of the great toe is the most susceptible joint ("podagra")

    • Other joints, especially those of the feet, ankles, and knees, are also commonly affected

    • May develop in periarticular soft tissues such as the arch of the foot

  • As the attack progresses

    • The pain becomes intense

    • The involved joints are swollen and exquisitely tender

    • The overlying skin is tense, warm, and dusky red

    • Fever is common

  • Asymptomatic periods of months or years commonly follow the initial attack

  • Tophi

    • May be found in cartilage, external ears, hands, feet, olecranon, prepatellar bursae, tendons, and bone

    • They are usually seen only after several attacks of acute arthritis

  • After years of recurrent severe monarthritis attacks, gout can evolve into a chronic, deforming polyarthritis of upper and lower extremities that mimics rheumatoid arthritis

Differential Diagnosis

Arthritis

  • Cellulitis

  • Septic arthritis

  • Pseudogout

  • Rheumatoid arthritis

  • Reactive arthritis (Reiter syndrome)

  • Osteoarthritis

  • Chronic lead poisoning (saturnine gout)

  • Palindromic rheumatism

Podagra

  • Trauma

  • Cellulitis

  • Sarcoidosis

  • Pseudogout

  • Psoriatic arthritis

  • Bursitis of first MTP joint (inflamed bunion)

Tophi

  • Rheumatoid nodules

  • Erythema nodosum

  • Gout

  • Coccidioidomycosis

  • Endocarditis (Osler nodes)

  • Sarcoidosis

  • Polyarteritis nodosa

Diagnosis

Laboratory Tests

  • During an acute flare, a single uric acid determination is normal in up to 25% of cases, so it does not exclude gout. However, serial measurements of serum uric ...

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