Gout Signs and Symptoms

Signs and Symptoms

Definition

Gout is a condition wherein there is increased urate in the body, also called hyperuricemia, that leads to deposition of monosodium urate monohydrate crystals in various tissues (eg joints, connective tissue, kidney)

Epidemiology

It is the most common inflammatory arthritis in men
In US and Europe, the estimated prevalence of gout is 3% of the adult population
Prevalence of gout in the Asia-Pacific region varies
- Ethnic groups in China and Malaysia (eg Malays, Tamils) were found to have higher uric levels as compared to the Japanese and Thai
- Taiwan is one of the countries in the world with the highest prevalence of gout

Pathophysiology

Hyperuricemia is a necessary precondition for the development of monosodium urate monohydrate crystal deposition but this has to be distinguished from gout, the clinical syndrome
Results in acute and chronic inflammation associated with changes in articular and periarticular structures

Causes of Hyperuricemia

Excessive uric acid production
- Inherited enzyme defects (eg hypoxanthine-guanine phosphoribosyl transferase deficiency, phosphoribosyl pyrophosphate synthetase overactivity, glycogen storage diseases, fructose-1-phosphate aldolase deficiency, myoadenylate deaminase deficiency, carnitine palmitoyltransferase II deficiency)
- Clinical disorders (eg myeloproliferative and lymphoproliferative disorders, malignancies, psoriasis, Down syndrome)
- Induced by diet, drugs, or toxins (eg Ethanol, excessive purine in diet, fructose, vitamin B12 deficiency, Nicotinic acid, cytotoxic drugs, Warfarin)
Decreased renal clearance
- Genetic disorders such as medullary cystic kidney disease, familial juvenile hyperuricemic nephropathy and uric acid transportasome mutations
- Chronic renal insufficiency, volume depletion (eg heart failure, volume loss), obesity, diabetic or starvation ketoacidosis, lactic acidosis, hyperparathyroidism, hypothyroidism, sarcoidosis
- Induced by diet or drugs (eg Aspirin, diuretics, Ciclosporin, Tacrolimus, Ethambutol, Pyrazinamide, Ethanol, Levodopa)
- Saturnine gout is a rare form of gout due to chronic lead exposure
  - Commonly seen in plumbers and those exposed to lead-based paints

Clinical Phases of Gout

Acute Gout

Usually manifests as an acute, self-limiting, monoarticular inflammatory arthritis in majority of patients
- Symptoms of a gout flare include severe pain, redness, swelling, warmth and disability
Lower extremity joints are affected more often than upper extremity joints
- Joints most commonly affected include the 1st metatarsophalangeal joint (podagra), forefoot, ankle, knee
Extra-articular sites (eg olecranon bursa and Achilles tendon) may also be involved
Attacks may occur and last from a few days to 2-3 weeks, with resolution of all inflammatory signs
- Early attack: <12 hours after onset of attack
- Well-established attack: 12-36 hours after onset of attack
- Late attack: >36 hours after attack onset

Intercritical Gout

Periods in between attacks when patient is free of symptoms
Asymptomatic joints may still have crystals detected in the synovial fluid

Chronic Gout

If hyperuricemia is not treated properly, intermittent acute gouty attack can develop into chronic gouty arthritis
There is persistent inflammation in the joints and connective tissues associated with bony erosions and deformities
Chronic tophaceous gout:
- Marked by polyarticular arthritis and the formation of tophi which are chalky deposits of monosodium urate
- Tophi are usually painless, appearing as firm, nodular or fusiform masses located subcutaneously
- Risk factors include polyarticular presentation, serum urate level 9 mg/dL (>0.54 mmol/L)
Presence of urate nephropathy or urate renal calculi

Risk Factors

Risk factors for gout and associated comorbidity should be assessed

Risk Factors Associated with Gout

Hyperuricemia
- Single most important risk factor for developing gout
Male sex
Menopausal women
Age
Purine-rich diet (eg meat, seafood)
Alcohol intake
Drug use (eg diuretics, low-dose Aspirin, Ciclosporin)
Lead exposure
Obesity
Renal insufficiency

Metabolic Abnormalities/Comorbidities Associated with Gout

Hypertension
Obesity
Dyslipidemia
Hyperglycemia and insulin resistance
Coronary artery disease
Type 2 diabetes mellitus
Renal insufficiency
Metabolic syndrome
Kidney stone

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