Gouty Arthritis

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, pinna of the 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

• 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, ...