Acute Gout
Gout usually develops in the joint of the big toe, and the first attack is usually at night. During an acute attack, the affected joint becomes hot, red, swollen, and extremely tender. These symptoms may be accompanied by fever. The attack may resolve in a few hours or last from days to weeks.
In men, the first acute attack of gout usually occurs between the ages of 40 and 60. In women, the first attack is more common after age 60 but can occur earlier. For most patients, the initial attack comes on suddenly. Others have reported pain involving the ankles, heels, or big toe that preceded the attack.
In 85% to 90% of cases, a single joint is involved in the first attack. Gout primarily affects joints of the lower extremities but can affect any joint. One survey of 354 gout patients showed that 76% had experienced gout in their big toe, 50% in their ankle or foot, and 32% in their knee. However, 25% had experienced an attack in their finger, 10% in their elbow, 10% in their wrist, and 11% in more than one site.
A definitive diagnosis can be made via aspiration of the joint and identification of intracellular needle-shaped urate crystals. Several other kinds of arthritis—such as rheumatoid arthritis or septic arthritis—can mimic gout, so proper diagnosis is important. However, a presumptive diagnosis of gout can be made in the case of acute monoarticular arthritis that is accompanied by hyperuricemia and responsive to anti-inflammatory therapy.
Dr. Robin Dore addressed challenges in gout diagnosis during a recent presentation to primary care physicians. You can watch and download Dr. Dore’s presentation. Watch Video
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Intercritical Gout
In most gout patients, a second attack occurs within 6 months to 2 years of the first attack. The majority of patients will have a second attack within 1 year, and 78% will have a second attack within 2 years. Only 7% of patients have no recurrence after 10 or more years. As the disease progresses, the frequency of attacks usually increases in untreated patients.
Later attacks are more likely to involve multiple joints, be more severe, last longer, and resolve more gradually. Joint damage progresses and may continue even between flares. Treatment decisions during intercritical periods must be weighed carefully with due consideration given to this fact and tailored to each patient.
Though diagnosis of gout may be difficult during intercritical periods, crystals may still be found in asymptomatic joints. Some evidence suggests that monosodium urate crystals persist as long as hyperuricemia persists, making aspiration a highly sensitive diagnostic approach even during intercritical periods.
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Chronic Tophaceous Gout
If hyperuricemia and acute gout are left untreated, the interval between attacks may disappear, leaving patients with persistent low-grade joint inflammation, joint deformity, and tophaceous deposits of urate crystals. The discomfort of chronic gout may still include episodes of acute pain.
Tophi can occur at various locations, generally, but not always, within the same joint affected by acute gout. The tophi may not be painful, but periodic acute inflammation can occur around the site, causing intense pain. Extensive joint damage and the formation of very large tophi can lead to crippling deformities, particularly of the hands and feet.
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