Gout

Gout is a monoarthropathy caused by deposition of monosodium urate crystals. 

Hyperuricaemia risk factors

• Male gender
• Chronic kidney disease
• Diuretics
• Purine rich diet: alcohol, meat, seafood
• Obesity

Clinical features

• Tender, inflamed joint
  • Usually a monoarthritis
  • Commonly affects first metatarsophalangeal joint
  • Other joints include ankles, knees, wrists, finger joints
  • Arthralgia worse at night
• Acute episodes last around 2 weeks 
• Other features of hyperuricaemia
  • Gouty tophi
  • Renal nephrolithiasis

Gout

Gouty tophi

Investigations

• Bloods: uric acid level (hyperuricaemia seen in gout, but uric acid level may be falsely low or normal during attack)
• Needle aspiration of synovial fluid – gold standard 
  • Send for polarising microscopy 
  • Send for microbiology: to rule out septic arthritis
• X-Ray

Management

• Treat cause
  • Lifestyle: keep hydrated, avoid purine rich food/drink, avoid fasting, lose weight
  • Medication review: thiazides and loop diuretics can trigger gout
• Acute management: NSAIDs, colchicine or corticosteroids
• Prevention with urate-lowering therapies: consider starting allopurinol or febuxostat if multiple flares, gouty tophi or arthritis, CKD, or on diuretics (NB: starting urate-lowering therapy can trigger an acute episode of gout so wait 2-4 weeks after an acute flare and offer colchicine cover for first 1-3 months)

Reference: NICE ‘NG219 Gout: diagnosis and management’ 2022

Questions

What are the classical features of gout on an X-ray?

Oops! This section is restricted to members. Click here to signup!

What is pseudogout?

Oops! This section is restricted to members. Click here to signup!

What are the findings of gout and pseudogout on polarising microscopy?

Oops! This section is restricted to members. Click here to signup!

Try some OSCE stations

1. Tophaceous gout exam
2. Gout history and spotter
3. Foot and ankle exam
4. Find lots more here!