Clinical features of gout

Key Points

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An acute gout flare is characterized by abrupt and rapid onset of extreme pain, within 24 hours, starting usually at night or early morning, with resolution within days to weeks.
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In men the initial flare is usually monoarticular, whereas in postmenopausal women it may be oligo or polyarticular.
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The most commonly involved joints are the metatarsophalangeal joints, affected in 50% of cases, followed by the ankle, midfoot, and hands.
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The erythema overlying the affected joint/s during a flare is characteristic of gout and may extend beyond the joint, leading to a monosodium urate (MSU) crystal-induced cellulitis. Other signs of inflammation include swelling, warmth, decreased range of motion, and extreme tenderness.
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Patients with gout may be asymptomatic during the intercritical period, but MSU crystal formation and deposition and inflammation may continue.
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Over several years of having MSU crystal deposition, chronic tophaceous gout may ensue, with tophaceous deposits observed mostly as articular and periarticular subcutaneous deposits.

Gout is the most common inflammatory arthritis in men over 40; however, many patients are diagnosed with gout before the age of 40. Men attain their “adult” serum urate (SU) levels around puberty, whereas women do not reach their maximum SU levels until after menopause, due to the uricosuric effect of estrogens, leading to an increase in the risk of gout in women postmenopause. This difference in the duration of hyperuricemia helps explain the male predominance of gout.

In 1859, Garrod proclaimed that “the deposited urate of soda may be looked upon as the cause, and not the effect, of gouty inflammation.” This statement remains as true today as it was then. The association between gout and monosodium urate (MSU) crystal deposition has been clearly established.

Gout has been described as a chronic disease characterized by four distinct disease states ( Fig. 194.1 ): asymptomatic hyperuricemia and the clinical states, which include acute gout flares, intervals between flares that the patient has already had a gout flare but is free of acute flares and advanced gout, which includes tophaceous and erosive gout. It has become clear that during the intervals between flares, when the patient is asymptomatic, chronic inflammation is often present.

The gout flare is the most dramatic and distinctive manifestation of gout. An acute flare of arthritis in one or more joints is usually the first sign of gout. The flare is commonly monoarticular in men and oligoarticular or polyarticular during later flares in men and initial flares in postmenopausal women, lasting from days to weeks. The inflammatory arthritis in patients with gout is caused by MSU crystal formation and deposition as a result of chronically elevated levels of urate in plasma and extracellular fluids. Flares are initially separated by intervals of complete freedom from all symptoms; however, as the disease progresses, the intervals between flares may shorten and the flares may lengthen, leaving evidence of chronic arthritis, with some patients having persistence of pain and inflammation during the intervals between flares.

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