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 5-7 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
There are three manifestations of gout used to classify the severity of gout.
Gout flares, Tophus formation and bony erosions, and Chronic persistent arthritis.
Read more below.
Gout flares
Uric acid crystals that have formed over years or decades of hyperuricemia will at some time lead to a sudden onset of severe pain, swelling and tenderness. This usually occurs in one or two joints in the feet or legs. The intensity of the pain is usually described as excruciating (8 to 10 out of 10 on a standard pain scale). The affected joints are very tender, even to the lightest of touch. Without treatment, these symptoms may last for 5-10 days and weight bearing is very difficult. Recurrent flares may occur in the same joint or other joints of the upper or lower extremities.
Tophus formation and bony erosions
After five or more years of recurrent flares, the patient with gout may develop tophi under the skin and around joints. While generally not painful, tophi can be disfiguring and interfere with normal joint function. The presence of tophi close to bones can lead to bone and cartilage destruction creating further deformities in the affected joints.
Chronic persistent arthritis
During the early stages of gout, the inflammatory arthritis is intermittent and during the periods between flares, joints may feel and function normally. Years to decades after the initial flare, flares may continue to be a recurrent problem but the intervals between flares have now become painful on a daily basis. Adequate treatment with appropriate urate-lowering therapies early on in the course of gout should prevent or eliminate all three of the gout manifestations from occurring.
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:
- Instep
- Ankle
- Heel
- Knee
- Achilles Tendon
- Wrist
- Finger
- Elbow
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 CPPD deposition disease. 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.
CME Courses
The Gout Education Society believes that continuing education for medical professionals and their staff is crucial when it comes to keeping up with the latest in gout treatment, diagnosis and management.
ACR Guidelines
In October 2012, the American College of Rheumatology (ACR) published its long anticipated “Guidelines for the Management of Gout.” In September 2015, ACR expanded on the existing guidelines and released new classification criteria about gout.
Gout Education Library
With gout on the rise, it is essential that all patients, especially those touched by gout, are knowledgeable about this serious disease. You can always learn more from your doctor during regular visits. Take a stand on gout!
