Signs and symptoms of gout
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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Acute gout is the most common early manifestation of gout.
The most common site for an attack is the big toe. Involvement of this joint is called podagra. The big toe is affected between 75-90 per cent of the time with more than 50 per cent of patients experiencing their first attack in this area.
Eighty per cent of attacks involve a single joint, usually the foot, ankle, or knee. The onset is generally at night or very early in the morning and the joint becomes swollen, red, warm, and very painful.
Fever may occur and an infected joint should be ruled out.
Early attacks subside over 3 to 10 days. Skin overlying the joint may peel. Attacks that develop later will tend to last longer, involve more joints, and occur more often. In those patients where the disease is poorly controlled, attacks may begin to affect multiple joints. This picture may present confusion with other types of arthritis.
The period between acute attacks is called the intercritical period. Most patients who are not treated for gout will have another attack within two years of the first one. Sometimes, if a patient has involvement of the hands at this stage, their disease may be confused with rheumatoid arthritis.
Chronic tophaceous gout describes a situation where deposits of uric acid will develop in the ear, elbows, front of the knees, Achilles tendons, and hands. These deposits of uric acid may cause the overlying skin to ulcerate and chalky deposits of uric acid will leak out. Risk factors for the development of tophaceous gout are: early age of onset, inadequate treatment, frequent attacks, very high levels of uric acid in the blood, involvement of the upper extremities, and attacks affecting multiple joints.
Kidney involvement from gout comes in two varieties. The first is uric acid stones. The frequency of stones increases as the serum uric acid increases and as the kidney increases the amount of uric acid excreted. The second consequence of gout in the kidney is deposits of uric acid in the kidney tissue. Uric acid kidney disease, if it progresses, causes hypertension and protein leaks in the urine. Eventually, it may also cause kidney failure.
Uric acid deposits can occur almost anywhere. One relatively common presentation is for gout to develop in the distal row of finger joints. This can be confused with osteoarthritis. Typically, older women on diuretic therapy present with this syndrome.
A few diagnostic laboratory tests may be helpful. The first is the presence of an elevated serum uric acid level at the time of an attack. A word of warning... patients can have normal serum uric acids at the time of attacks and elevated serum uric acids can occur in other arthritic disease states such as psoriatic arthritis and pseudogout. Certain drugs such as aspirin or diuretics can also raise serum uric acid levels.
Patients may have elevated white blood cell counts and elevated erythrocyte sedimentation rates.
The best method for establishing the diagnosis is to examine fluid aspirated from an acutely inflamed joint. Patients with gout almost always have monosodium urate crystals in the joint fluid. A polarizing microscope must be used and the attack has to be relatively acute. If some time has gone by (more than 3 days after the onset of the attack), crystals may not be evident. An experienced lab tech or rheumatologist should look at the fluid because the crystals are not that easy to identify. The fluid will also have many white blood cells and it’s important to rule out the presence of simultaneous infection.
X-rays will demonstrate soft tissue swelling. With long established gout, bony erosions will occur.
In recent years, diagnostic ultrasound has been used to help with diagnosis. Gout has a typical presentation on ultrasound. Ultrasound guidance for joint aspiration is also useful.
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