Gout

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

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?

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What is pseudogout?

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

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Try some OSCE stations

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