Acute gout

Acute gout:

• attacks usually start in the early morning
  • often involves only a single joint but oligo-articular and polyarticular gout can occur especially in elderly patients, common sites include:
    • metatarsophalangeal (MTP) joint of the big toe (75%)
    • ankle joint
    • finger joints
    • olecranon bursae
  • these attacks are characterised by
    • severe pain (‘worst ever’) and tenderness in joints
      • pain reaches a peak within just 6–24 h of onset and then resolve spontaneously (within several days to 2 weeks) - this is almost pathognomonic of crystal synovitis
      • often the patients are unable to wear socks or touch bedsheets during flare-ups due to severe pain (2)
    • swollen and hot joints
    • overlying skin is red and shiny (3)
• attacks are often spontaneous but may be triggered by direct trauma to a joint, intercurrent illnesses, operation, alcohol, or unaccustomed exercise
• during the attack fever, nausea and mood swings may be present.
• there can be skin desquamation over the inflamed area (2)

Further attacks are seen after a variable period of time. These attacks may

• increase in severity and frequency
• involve different joint sites
• become oligo- or polyarticular (3)

In rare instances, monosodium urate may be deposited in the conjunctiva and cause sore eyes.

Note:

• he patient will usually have a chronically elevated uric acid level however, during an acute attack of gout the uric acid concentrations may fall

Reference:

• (1) Doherty M. New insights into the epidemiology of gout. Rheumatology (Oxford). 2009;48 Suppl 2:ii2-ii8.
• (2) Eggebeen AT. Gout: an update. Am Fam Physician. 2007;76(6):801-8.
• (3) Roddy E. Revisiting the pathogenesis of podagra: why does gout target the foot? J Foot Ankle Res. 2011;4(1):13.