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Gout

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of gout.

Alternative Names

Hyperuricemia

Symptoms

Gout typically strikes the joint of the big toe, but may affect other joints, such as the ankle or knee. Common symptoms of gout include:

• Inflammation
• Pain
• Redness
• Stiffness
• Swelling

A gout attack develops very quickly. The first attack often occurs at night. In middle-aged adults, symptoms are more likely to occur in one joint, most often in the lower limbs. About 60% of cases in this age group first occur in the big toe.

In elderly people, symptoms are more likely to occur in several joints in the upper arms and hands, particularly the fingers.

The specific symptoms depend on the stage of the disease. Gout is often divided into four stages:

• Asymptomatic hyperuricemia
• Acute gouty arthritis
• Intercritical gout
• Chronic tophaceous gout

Asymptomatic Hyperuricemia

Asymptomatic means there are no symptoms. Asymptomatic hyperuricemia is considered the first stage of gout. MSU slowly builds up. It lasts for an average of 30 years.

Note: Hyperuricemia does not inevitably lead to gout. In fact, less than 20% of cases develop the full-blown arthritic disease.

Symptoms of Acute Gouty Arthritis

Acute gouty arthritis occurs when the first symptoms of gout appear. Sometimes the first signs of gout are brief twinges of pain (petit attacks) in an affected joint, which can precede the actual full-blown condition by several years. MSU crystals form at normal body temperature when concentrations in the blood reach 7 mg/dL. At lower temperatures, crystals form at lower concentrations. Since blood temperature falls the further blood gets from the heart, gout strikes the toes and fingers first.

Symptoms of acute gouty arthritis include:

• Severe pain at and around the joint
  • May feel like "crushing" or a dislocated bone
  • Walking and the weight of bed sheets may be unbearable
  • Usually takes 8 - 12 hours to develop
  • Occurs late at night or early in the morning and may wake you up
• Swelling that may go beyond the joint may extend beyond the joint
• Red, shiny, tense skin over the affected area, which may peel after a few days
• Chills and mild fever, loss of appetite, and feelings of ill health

Most often symptoms first start in one joint.

Monoarticular Gout. Gout that occurs in one joint is called monoarticular gout. Approximately 60% of all first-time monoarticular gout attacks in middle-aged adults occur in the big toe. This occurrence is known as podagra . Symptoms can also occur in other locations.

Polyarticular Gout. If more than one joint is affected, it is known as polyarticular gout . Multiple joints are affected in only 10 - 20% of first attacks. Older people are more likely to have polyarticular gout. The most frequently affected joints are the foot, ankle, knee, wrist, elbow, and hand. The pain usually occurs in joints on one side of the body and it is usually, although not always, in the lower legs and feet. People with polyarticular gout are more likely to have a slower onset of pain and a longer delay between attacks. People with polyarticular gout are also more likely to experience low-grade fever, loss of appetite, and a general feeling of poor health.

An untreated attack will typically peak 24 - 48 hours after the first appearance of symptoms, and go away after 5 - 7 days. However, some attacks last only hours, while others persist as long as several weeks.

Intercritical Gout

Intercritical gout is the term used to describe the periods between attacks. The first attack is usually followed by a complete remission of symptoms, but left untreated, gout nearly always recurs in the future. One study reported that 62% of subjects had at least one further attack within a year. At the end of 2 years, 78% of patients had a recurrence. After 10 years, 93% of the patients reported repeat attacks.

Symptoms of Chronic Tophaceous Gout

Development of Chronic Pain. When gout remains untreated, the intercritical periods typically become shorter and shorter, and the attacks, although sometimes less intense, can last longer. Over the long term (about 10 - 20 years) gout becomes a chronic disorder characterized by constant low-grade pain and mild or acute inflammation. Gout may eventually affect several joints, including those that may have been free of symptoms at the first appearance of the disorder. In rare cases, the shoulders, hips, or spine are affected.

Symptoms of Tophi. Tophi, the knobby MSU crystal deposits that form during chronic gout, generally form in the following locations:

• Curved ridge along the edge of the outer ear
• Forearms
• Elbow or knee
• Hands or feet -- older patients, particularly women, are more likely to have gout in the small joints of the fingers.
• Around the heart and spine (rare)

Tophi are generally painless. However, they can cause pain and stiffness in the affected joint. Eventually, they can also erode cartilage and bone, ultimately destroying the joint. Large tophi under the skin of the hands and feet can give rise to extreme deformities.

• Review Date: 11/30/2006
• Reviewed By: Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

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