Gout
Definition
Gout (also known as podagra when it involves the big toe) is a medical
condition usually characterized by recurrent attacks of acute
inflammatory arthritis—a red, tender, hot, swollen joint. The metatarsal-
phalangeal joint at the base of the big toe is the most common affected, in
around half of all cases. However, it may also present as tophi, kidney
stones, or urate nephropathy. It is caused by elevated levels of uric acid in
the blood which crystallize and are deposited in joints, tendons, and
surrounding tissues.
Signs and symptoms
Gout can present in a number of ways, although the most usual is a
recurrent attack of acute inflammatory arthritis (a red, tender, hot,
swollen joint). The metatarsal-phalangeal joint at the base of the big toe is
affected most often, accounting for half of cases. Other joints such as the
heels, knees, wrists and fingers may also be affected. Joint pain usually
begins over 2–4 hours and during the night. The reason for onset at night
is due to the lower body temperature during this time. Other symptoms
that may occur along with the joint pain include fatigue and a high fever.
Long-standing elevated uric acid levels (hyperuricemia) may result in
other symptomatology including hard, non-painful deposits of uric acid
crystal known as tophi. Extensive tophi may lead to chronic arthritis due
to bone erosion. Elevated levels of uric acid may also lead to crystals
precipitating in the kidneys resulting in stone formation. This may result
in urate nephropathy.
Cause
Hyperuricemia is the underlying cause of gout. This can occur for a
number of reasons including dietary, genetic, or underexcretion of urate,
the salts of uric acid. Renal underexcreation of uric acid is the primary
cause of hyperuricaemia in about 90% of cases while overproduction is
the cause in less than 10%.About 10% of people with hyperuricemia
develop gout at some point in their lifetime. The risk however varies
depending on the degree of hyperuricemia.
Medication
Diuretics have been associated with attacks of gout however a low dose
of hydrochlorothiazide (HCTZ) does not seem to increase the risk. Other
medicines that have been associated include niacin and aspirin
(acetylsalicylic acid). Cyclosporine is also associated with gout,
particularly when used in combination with hydrochlorothiazideas are the
immunosuppressive drugs ciclosporin and tacrolimus.
Diagnosis
Gout may be diagnosed and treated without further investigations in
someone with hyperuricemia and the classic podagra. Synovial fluid
analysis should be done however if the diagnosis is in doubt. X-rays
while useful for identifying chronic gout have little utility in acute
attacks.
Prevention
Both lifestyle changes and medication can decrease uric acid levels.
Dietary and lifestyle choices that are effective include reducing intake of
food high in purines such as meat and seafood, consuming adequate
vitamin C, limiting alcohol and fructose consumption and avoiding
obesity. Vitamin C intake of 1,500 mg per day decreases the risk of gout
by 45% compared to 250 mg per day. Coffee but not tea consumption is
associated with a lower risk of gout. Gout may be secondary to sleep
apnea via the release of purines from oxygen-starved cells. Treatment of
apnea can lessen the occurrence of attacks.
Treatment
The initial aim of treatment is to settle the symptoms of an acute attack.
Repeated attacks can be prevented by different drugs used to reduce the
serum uric acid levels. Ice applied for 20 to 30 minutes several times a
day decreases pain. Options for acute treatment include nonsteroidal anti-
inflammatory drugs (NSAIDs), colchicine and steroids.
Gout presenting in the metatarsal-phalangeal joint of the big toe.
Note the slight redness of the skin overlying the joint.
Tophus of the toe, and over the external maleolus.
Nodules of the finger and helix of the ear representing gouty tophi.
Tophus of the knee
