GOUT FAST FACT
50% of first-time attacks occur in the big toe.
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Gouty Arthritis Diagnosis & Stages
To confirm a gout diagnosis, the gold standard is still aspiration of synovial fluid from the inflamed joint and the presence of intracellular monosodium urate crystals seen with a polarizing microscope.
Presumed gout is a diagnosis based on a pattern of recurrent acute flares of monoarthritis in the historical setting of hyperuricemia. A clear and detailed history of an acute gout attack followed by an asymptomatic period and then recurrence is valuable in moving the diagnosis toward gout.
Persons experiencing an acute gout attack will be in acute pain. Even the slightest pressure will be unbearable. A patient may also present with systemic features such as fever, as well as a leukocytosis and elevation of the erythrocyte sedimentation rate.
Gout may be mistaken for a number of other conditions.
Diagnosis: Gouty arthritis or rheumatoid arthritis?
Persons may be incorrectly diagnosed as having rheumatoid arthritis (RA), especially if tophi are mistaken for rheumatoid nodules. Gout may progress from initial podagra to an RA-like chronic deforming polyarthritis without remissions but with synovial thickening and tophi. But unlike RA, a flare in one joint may coincide with subsidence of inflammation in another joint. Likewise, a patient can be incorrectly diagnosed as having gouty arthritis when in fact they have RA.
Diagnosis: Gouty arthritis or pseudogout?
Pseudogout is another crystal-induced arthritis but calcium pyrophosphase dehydrate crystals are the culprit, not uric acid crystals.
Gout has been mistaken for septic joint and vice versa. Gout and osteoarthritis (OA) often coexist and the more significant X-ray finding may be the degenerative changes.
Although hyperuricemia is the metabolic underpinning of gout it is often not elevated during an acute attack.
In addition, hyperuricemia alone does not mean gout. In fact, most people with hyperuricemia do not develop the disease. Therefore, hyperuricemia does not equal gout, although the higher the uric acid, the greater the likelihood that a gout diagnosis will be determined sooner or later.
Onset of gout before age 30 or in premenopausal women could suggest an inherited enzyme defect, severe renal disease or indication by a drug or toxic agent, such as ethanol or lead. Transplanted persons on cyclosporine also may develop gout early.
Stages of Gouty Arthritis
There are four stages of gout. With proper management of lifestyle and medication, patients can avoid the latter stages. As the disease progresses in noncompliant patients and those to whom the management scheme has not been appropriately communicated, clinical outcomes may be severe, with marked impairment of activities of daily living and the ability to work.
Gout Stage 1 – Asymptomatic Hyperuricemia
- Elevated levels of uric acid, which could represent a precursor to clinical gout.
- No symptoms of gout.
- Treatment is usually not necessary at this stage.
Most patients will have elevated levels of uric acid for many years before their first attack and many patients with elevated uric acid will never have an attack. The risk of an attack increases as the uric acid level increases.
Gout Stage 2 – Acute Gout Attack
Years of sustained hyperuricemia may lead to small deposits of sodium urate crystals in and around the joint space. Following certain triggering events, these deposits release crystals into the joint space, triggering an acute attack.
- Patient wakens at night by intense pain and swelling in the joint.
- Pain goes away (even without treatment) after 3 to 10 days.
While the patient may not experience another attack for months or even years, it is important to evaluate for risk factors.
Gout Stage 3 – Intercritical Gout
- Patient has experienced a prior gout attack.
- Symptom-free period.
- Joints functioning normally.
- Ideal time to work on a plan to event future attacks and pain
- Determine if medications may aggravate the condition.
- Review dietary guidelines about avoiding purine-rich foods and fructose as part of a healthy, balanced diet.
- Assess alcohol intake and determine if it is advisable to cut back on consumption.
- Assess BMI and if there is a need to lose weight.
- Discuss therapeutic options to prevent or treat future attacks.
Despite a lack of symptoms, there is ongoing inflammation. A low level of inflammation may be associated with risks for heart disease and stroke. Unfortunately, if ignored, this phase is frequently followed by continued attacks of gout.
Gout Stage 4 – Chronic Tophaceous Gout
After many years of gout attacks, some patients enter into the most disabling stage of gout.
- Uric acid crystals have been depositing within and around the joint space.
- Arthritis is chronic.
- Urate pools expand and deposits of crystals or tophi collect in cartilage, tendons, soft tissues and elsewhere.
- Deformity and destruction to affected bone and cartilage.
- Possible damage to the kidneys.
- Ongoing destructive inflammatory process.
With proper medical attention and treatment, most patients will not progress to this advanced stage.