Symptoms & Stages
Clinical Presentation of Gout
Gouty arthritis is extremely painful. Patients experiencing a gout flare regularly rate their level of pain as a 9 or 10 on a standard pain scale.
When gout is in its intermittent stage, most flares last for several days. The hallmarks include:
- Sudden and rapid onset of severe pain, often in a lower extremity at first
- Stiffness and swelling of the affected joint, including inability to bear weight on or touch the joint
- Warmth and erythema, which is often confused with infectious cellulitis
For more than half of people, gout begins in the great toe. Known as podagra, approximately 90 percent of gout patients will suffer gout of the great toe at some point during the course of the disease. Untreated, sustained hyperuricemia can lead to gouty arthritis in joints other than the lower extremities. For some, it becomes polyarticular. Other joints commonly affected include:
- Achilles Tendon
Distinguishing Gout and Other Conditions
Gout can be challenging to diagnose. It may be confused with other conditions such as cellulitis or a septic joint. Like gout, infectious arthritis can have a rapid onset and can be a very painful inflammation. Most septic arthritis is spread from other foci, such as a urogenital infection, an abscess or a post-surgical infection. Arthrocentesis is diagnostic.
Calcium pyrophosphate crystals may cause an acute arthritis known as pseudogout, or CPDD. Pseudogout has some resemblance to gout, but presents with milder swelling and pain. It is usually found among those who are 65 and older, with osteoarthritis being a common risk factor. In rare cases, patients can have mixed crystal disease. Crystal disease and infection can co-exist as well.
Clinical Stages of Gout
The natural course of classic gout passes through several stages.
Stage 1 – Asymptomatic Hyperuricemia
Hyperuricemia in men and women is defined as a state in which the serum urate level exceeds 6.8 mg/dL. Above this concentration urate ions are insoluble in physiologic fluids at normal pH and temperature. The term asymptomatic hyperuricemia is the state in which serum urate concentration is above the solubility levels, but no symptoms of gout or kidney stones have manifested. However, MSU crystals can develop and be deposited as micro-tophi. They tend to remain stable for long periods. This period can last decades. Treatment is not recommended at this time, except in rare cases. Regular monitoring of uric acid levels and encouraging patients to make healthy diet and lifestyle adjustments should be encouraged.
Stage 2 – Acute Gout Flares
This is the stage most clinicians think of as gout. It is classified by an abrupt onset of severe joint inflammation, often at night, which wakes the sufferer. Acute gout flares usually occur in men over the age of 45 and in post-menopausal women. Early flares last three to 10 days and frequently affect the lower extremity – with the great toe often the first site. Low-grade fever and malaise may occur, and leukocytosis and elevations of inflammatory markers are also common. Pain is often so severe that patients visit the emergency room for care. While the patient may not experience another flare for months or even years, it is important to evaluate for risk factors.
Stage 3 – Intercritical Gout
During this stage, the previous flare has resolved and the patient is without symptoms. The joints are functioning normally. It is understood that if urate-lowering therapy is not introduced, urate crystals will continue to quietly accumulate. Recurrence rates after the first flare of gout are 60 percent in one year, 78 percent in two years and 84 percent in three. This can be more rapid in the elderly, those with very high uric acid levels, those with kidney disease and those who are on cyclosporine. If hyperuricemia is not treated in this stage, painful flares of gout are likely to continue.
Stage 4 – Advanced Gout (Chronic Tophaceous Gout)
In this stage, pain-free intercritical periods disappear and the patient develops a chronic arthritis. Tophi are often apparent and can destroy bone, leading to deformities. Chronic synovial inflammation persists, leading to stiffness and soreness. Acute flares still develop. The process is now polyarticular, affecting joints of both the lower and upper extremities. With intervention and treatment, most gout patients will not progress to this advanced stage. Advanced gout can be so deforming that it is often clinically confused with rheumatoid arthritis.