Gout is characterized by acute and recurrent arthritis mediated by the formation of monosodium uric (MSU) acid crystals within the joints and surrounding tissues. This results in pain, erythema, and inflammation. Elevated serum uric acid (SUA) concentrations may predispose a patient to symptoms of gout. This elevation is traditionally a result of a defect in purine metabolism, a decrease in uric acid excretion, increased nucleic acid turnover, or increased purine production. Regardless of the cause, excessive intake of high purine foods contributes to hyperuricemia and gout exacerbations (Table 48-1). SUA concentrations are higher in obesity, chronic kidney disease, and in patients who consume alcohol. However, gout flares can occur in individuals with normal SUA levels and elevated SUA concentrations do not always lead to the development of gout.
TABLE 48-1Dietary Components Which May Affect Serum Uric Acid (SUA) Levels ||Download (.pdf) TABLE 48-1 Dietary Components Which May Affect Serum Uric Acid (SUA) Levels
|Increased SUA |
|• Red and organ meat (liver, kidney), seafood (shellfish, anchovies), beer, and spirits |
|• Sugar-sweetened soft drinks and fructose |
|Decreased SUA |
|• Vitamin C |
|• Coffee |
Gout is a self-limiting monoarthritis disease, often involving a lower extremity joint. Additionally, 90% of patients experience podagra (acute attacks in the great toe). Symptoms develop rapidly and include excruciating pain, erythema, warmth, and swelling near the affected joint (Table 48-2). Although acute attacks often occur spontaneously, they can be precipitated by stress, infection, surgery, or ingestion of alcohol or medications. Exacerbations initially occur infrequently; however, gout is an episodic disease and the number of attacks may vary widely. Gout can develop into a chronic disease with recurrent flare-ups, increasing in frequency over time. If untreated, an acute gouty attack may last 1 to 2 weeks, followed by an asymptomatic period.
TABLE 48-2Clinical Signs and Symptoms of Gout ||Download (.pdf) TABLE 48-2 Clinical Signs and Symptoms of Gout
|• Affected joint(s) are swollen, erythematous, and warm |
|• Mild fever |
|• Tophi may be present in chronic, severe disease (usually on ears, hands, wrists, elbows, or knees) |
|• Severe pain, swelling, and warmth in the affected joint(s) |
|• Attack is usually monoarticular; most common sites are metatarsophalangeal and knee joints |
|• Elderly patients may exhibit atypical presentation, such as insidious onset of symptoms and polyarticular joint involvement, often involving the hand or wrist joints |
In addition to traditional gout symptoms, patients may experience other complications including:
Tophi (urate crystal deposits that can damage surrounding soft tissue and cause significant pain and joint destruction)
Uric acid stones in the kidney (uric acid nephrolithiasis)
Chronic kidney disease
Clinical analysis of aspirated synovial fluid is the ...