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GoutandPseudogoutClinicalPresentation:History,PhysicalExamination,Complications

GoutandPseudogoutClinicalPresentation
Author:BruceMRothschild,MDChiefEditor:HerbertSDiamond,MDmore...
Updated:Sep21,2015

History
Thespontaneousonsetofexcruciatingpain,edema,andinflammationinthe
metatarsalphalangealjointofthegreattoe(podagraseetheimagebelow)is
highlysuggestiveofacutecrystalinducedarthritis.Podagraistheinitialjoint
manifestationin50%ofgoutcaseseventually,itisinvolvedin90%ofcases.
Podagraisnotsynonymouswithgout,however:itmayalsobeobservedinpatients
withpseudogout,sarcoidosis,gonococcalarthritis,psoriaticarthritis,andreactive
arthritis.

Gout.Acutepodagraduetogoutinelderlyman.

Otherthanthegreattoe,themostcommonsitesofgoutyarthritisaretheinstep,
ankle,wrist,fingerjoints,andknee.Inearlygout,only1or2jointsareusually
involved.Considerthediagnosisinanypatientwithacutemonoarticulararthritisof
anyperipheraljointexcepttheglenohumeraljointoftheshoulder.
Themostcommonsitesofpseudogoutarthritisarelargejoints,suchastheknee,
wrist,elbow,orankle.Casereportshavedocumentedcarpaltunnelsyndromeasan
initialpresentationofpseudogout.Casereportsofcalciumpyrophosphate(CPP)
crystalsformingmassesinthespinalligamentumflavumhavebeendocumented.
[67]Thesehaveledtobothsinglelevelandmultilevelmyelopathy.
Althoughcrystalinducedarthritisismostcommonlymonoarticular,polyarticular
acuteflaresarenotrare,andmanydifferentjointsmaybeinvolvedsimultaneously
orinrapidsuccession.Multiplejointsinthesamelimboftenareinvolved,aswhen
inflammationbeginsinthegreattoeandthenprogressestoinvolvethemidfootand
ankle.
Goutattacksbeginabruptlyandtypicallyreachmaximumintensitywithin812
hours.Affectedjointsarered,hot,andexquisitelytenderevenabedsheetonthe
swollenjointisuncomfortable.Theonsetofsymptomsinpseudogoutcanresemble
acutegoutorbemoreinsidiousandmayoccuroverseveraldays.
Untreated,thefirstattacksresolvespontaneouslyinlessthan2weeks.Ahistoryof
intermittentinflammatoryarthritis,inwhichthejointsreturntonormalbetween
attacks,istypicalofcrystallinedisordersandischaracteristicofgoutyarthritisearly
initscourse.
Goutinitiallypresentsaspolyarticulararthritisin10%ofpatients.Elderlywomen,
particularlywomenwithrenalinsufficiencywhoaretakingathiazidediuretic,can
developpolyarticulararthritisasthefirstmanifestationofgout.Theseattacksmay
occurincoexistingHeberdenandBouchardnodes.Suchpatientsmayalsodevelop
tophimorequickly,occasionallywithoutpriorepisodesofacutegoutyarthritis. [68,69,
70]

Thepatternofsymptomsinuntreatedgoutchangesovertime.Theattackscan
becomemorepolyarticular.Moreproximalandupperextremityjointsbecome
involved.Attackstendtooccurmorefrequentlyandlastlonger.
Eventually,patientsmaydevelopchronicpolyarticulararthritis,sometimesnearly
symmetrical,thatcanresemblerheumatoidarthritis.Indeed,chronicpolyarticular
arthritisthatbeganasanintermittentarthritisshouldpromptconsiderationofa
crystallinedisorderinthedifferentialdiagnosis.
Acuteflaresofgoutcanresultfromsituationsthatleadtoincreasedlevelsofserum
uricacid,suchastheconsumptionofbeerorliquor,overconsumptionoffoodswith
highpurinecontent,trauma,dehydration,ortheuseofmedicationsthatelevate
levelsofuricacid.Acuteflaresofgoutalsocanresultfromsituationsthatleadto
decreasedlevelsofserumuricacid,suchastheuseofradiocontrastdyeor
medicationsthatlowerthelevelsofuricacid,includingallopurinolanduricosurics.
Patientswithgouthaveasmuchas1000timesmoreuricacidinthebodyas
unaffectedindividualsdoandarealmosttwice(1.97times)aslikelytodevelop
renalstonesashealthyindividualsare[71]therefore,theymayhaveahistoryof
renalcolicandhematuria.Indeed,renalstonesmayprecedetheonsetofgoutin

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GoutandPseudogoutClinicalPresentation:History,PhysicalExamination,Complications

14%ofaffectedpatients.Whereas52%ofthesepatientsmayhavestones
composedentirelyofuricacid,20%maydevelopcalciumoxalateorsometimes
calciumphosphatestones. [72]
Becausegoutisfrequentlypresentinpatientswiththemetabolicsyndrome(eg,
insulinresistanceordiabetes,hypertension,hypertriglyceridemia,andlowlevelsof
highdensitylipoproteins)andbecausethepresenceoftheseassociateddisorders
canleadtocoronaryarterydisease,theseproblemsshouldbesoughtandtreatedin
patientsdiagnosedwithgout.
Itisimportanttoaskaboutahistoryofpepticulcerdisease,renaldisease,orother
conditionsthatmaycomplicatetheuseofthemedicationsusedtotreatgout.
Fever,chills,andmalaisedonotdistinguishcellulitisorsepticarthritisfromcrystal
inducedarthritis,becauseall3illnessescanproducethesesignsandsymptoms.A
carefulhistorymayuncoverriskfactorsforcellulitisorsepticarthritis,suchas
possibleexposuretogonorrhea,arecentpuncturewoundoverthejoint,orsystemic
signsofdisseminatedinfection.

PhysicalExamination
Patientsexperiencinganacuteattackofgoutorpseudogoutmostoftenpresent
withinvolvementofasinglejoint.However,alljointsmustbeexaminedto
determinewhetherthepatientsarthritisismonoarticularorpolyarticular.Involved
jointshaveallthesignsofinflammation:swelling,warmth,erythema,and
tenderness.
Theerythemaoverthejointmayresemblecellulitistheskinmaydesquamateas
theattacksubsides.Thejointcapsulebecomesquicklyswollen,resultinginaloss
ofrangeofmotionoftheinvolvedjoint.
Patientsmaybefebrileduringanacutegoutattack,particularlyifitispolyarticular.
However,itisimportanttolookforsitesofinfectionthatmayhaveseededthejoint
andcausedaninfectiousarthritisresemblingorcoexistingwithacutegoutyarthritis.
Migratorypolyarthritisisararepresentation.Polyarticulargoutcommonlyinvolves
thesmalljointsofthefingersandtoes,aswellastheknees.Aninflammatory
synovialeffusionmaybepresent.Uncommonly,acutegoutmaypresentascarpal
tunnelsyndrome.
Posteriorinterosseousnervesyndromeisararecompressionneuropathythat
manifestsasinabilitytoextendthefingersactively.Thesyndromehasbeen
reportedinapatientwithelbowswellingfromanattackofpseudogoutinthiscase,
treatmentwithintraarticularsteroidsledtoresolutionofthenervepalsy. [73]
Patientswithestablishedgoutmayhavechronicarthritis.Affectedjointsevidence
tendernessandswelling,withorwithoutredness,warmth,orjointdamage.

Tophi
Althoughgouttypicallycausesjointinflammation,itcanalsocauseinflammationin
othersynovialbasedstructures,suchasbursaeandtendons.Tophiarecollections
ofuratecrystalsinthesofttissues.Theytendtodevelopafteraboutadecadein
untreatedpatientswhodevelopchronicgoutyarthritis.Tophimaydevelopearlierin
olderwomen,particularlythosereceivingdiuretics. [68,69,70]
Tophiareclassicallylocatedalongthehelixoftheear,buttheycanbefoundin
multiplelocations,includingthefingers,thetoes,theprepatellarbursa,andalong
theolecranon,wheretheycanresemblerheumatoidnodules(seetheimages
below).Rarely,acreamydischargemaybepresent. [74,75]Thefindingofan
apparentrheumatoidnoduleinapatientwithanegativerheumatoidfactorassayor
ahistoryofdrainagefromanoduleshouldpromptconsiderationofgoutinthe
differentialdiagnosis. [76]

Gout.Tophaceousdepositsinear.

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Gout.Tophaceousdepositsonelbow.

Gout.Chronictophaceousgoutinuntreatedpatientwithendstagerenaldisease.

Eyeinvolvement
Thefolkloresurroundinggouthasalsoinvolvedtheeye,andbeforethe20th
century,amyriadofcommonandunusualocularsymptomswerefalselyascribedto
gout.Medicalsciencehassincedocumentedeyeinvolvementasararebutdefinite
aspectofgout.Allmanifestationsofgoutintheeyearesecondarytodepositionof
uratecrystalswithintheoculartissue. [77,78]
Tophihavebeendescribedintheeyelids. [79,80,81]Conjunctivalnodulescontaining
needlelikecrystalshavebeendescribedwithintheinterpalpebralareas,sometimes
associatedwithamildmarginalkeratitis.Bandkeratopathywithrefractile,yellow
crystalsinthedeepcornealepithelialcellsandattheleveloftheBowman
membranearenotuncommon. [82]
Blurringofvisionfromthecornealhazeoraforeignbodysensationduetoepithelial
breakdownmayoccur.GoutrarelycanbeassociatedwithanterioruveitisDuke
EldermentionsthisasacauseofhemorrhagiciritisinhisclassicTextBookof
Ophthalmology.Scleritisandtendinitishavealsobeendescribed.Besidesthe
cornea,theiris,anteriorchamber,lens,andsclerahavebeenfoundtoharborurate
crystalsonpostmortemexamination,uratecrystalshavealsobeenfoundintarsal
cartilageandinthetendonsofextraocularmuscles. [77,78]

Complications
Complicationsofgoutincludethefollowing:
Severedegenerativearthritis
Secondaryinfections
Urateoruricacidnephropathy
Increasedsusceptibilitytoinfection
Uratenephropathy
Renalstones
Nerveorspinalcordimpingement [83,84]
Fracturesinjointswithtophaceousgout [85]
DifferentialDiagnoses

ContributorInformationandDisclosures
Author
BruceMRothschild,MDProfessorofMedicine,NortheastOhioMedicalUniversityAdjunctProfessor,
DepartmentofBiomedicalEngineering,UniversityofAkronResearchAssociate,UniversityofKansasMuseum
ofNaturalHistoryResearchAssociate,CarnegieMuseum
BruceMRothschild,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationforthe
AdvancementofScience,AmericanCollegeofRheumatology,InternationalSkeletalSociety,NewYork
AcademyofSciences,SigmaXi,SocietyofSkeletalRadiology
Disclosure:Nothingtodisclose.
Coauthor(s)
MarkLFrancis,MDProfessorofMedicalEducation,DepartmentofMedicalEducation,PaulLFosterSchoolof
Medicine,TexasTechUniversityHealthSciencesCenter
MarkLFrancis,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofPhysicians,PhiBeta
Kappa

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GoutandPseudogoutClinicalPresentation:History,PhysicalExamination,Complications

Disclosure:Nothingtodisclose.
AnneVMiller,MDChief,RheumatologyDivisionAssistantProfessorofInternalMedicine,Departmentof
Medicine,DivisionofRheumatology,SouthernIllinoisUniversitySchoolofMedicine
AnneVMiller,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanCollegeof
Physicians,AmericanCollegeofRheumatology,InternationalSocietyforClinicalDensitometry
Disclosure:Nothingtodisclose.
ChiefEditor
HerbertSDiamond,MDVisitingProfessorofMedicine,DivisionofRheumatology,StateUniversityofNewYork
DownstateMedicalCenterChairmanEmeritus,DepartmentofInternalMedicine,WesternPennsylvaniaHospital
HerbertSDiamond,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanCollege
ofPhysicians,AmericanCollegeofRheumatology,AmericanMedicalAssociation,PhiBetaKappa
Disclosure:Nothingtodisclose.
Acknowledgements
RichardWAllinson,MDAssociateProfessor,DepartmentofOphthalmology,TexasA&MUniversityHealth
ScienceCenterSeniorStaffOphthalmologist,ScottandWhiteClinic
RichardWAllinson,MD,isamemberofthefollowingmedicalsocieties:AmericanAcademyofOphthalmology,
AmericanMedicalAssociation,andTexasMedicalAssociation
Disclosure:Nothingtodisclose.
LawrenceHBrent,MDAssociateProfessorofMedicine,JeffersonMedicalCollegeofThomasJefferson
UniversityChair,ProgramDirector,DepartmentofMedicine,DivisionofRheumatology,AlbertEinsteinMedical
Center
LawrenceHBrent,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationforthe
AdvancementofScience,AmericanAssociationofImmunologists,AmericanCollegeofPhysicians,and
AmericanCollegeofRheumatology
Disclosure:AbbottHonorariaSpeakingandteachingCentocorConsultingfeeConsultingGenentech
Grant/researchfundsOtherHGS/GSKHonorariaSpeakingandteachingOmnicareConsultingfeeConsulting
PfizerHonorariaSpeakingandteachingRocheSpeakingandteachingSavientHonorariaSpeakingand
teachingUCBHonorariaSpeakingandteaching
AndrewADahl,MDDirectorofOphthalmologyTeaching,MidHudsonFamilyPracticeInstitute,TheInstitute
forFamilyHealthAssistantProfessorofSurgery(Ophthalmology),NewYorkCollegeofMedicine
AndrewADahl,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanAcademyof
Ophthalmology,AmericanCollegeofSurgeons,AmericanMedicalAssociation,AmericanSocietyofCataract
andRefractiveSurgery,andWildernessMedicalSociety
Disclosure:Nothingtodisclose.
PaulEDiCesare,MD,FACSProfessorandChair,DepartmentofOrthopedicSugery,UniversityofCalifornia,
Davis,SchoolofMedicine
PaulEDiCesare,MD,FACSisamemberofthefollowingmedicalsocieties:AmericanAcademyofOrthopaedic
Surgeons,AmericanCollegeofSurgeons,andSigmaXi
Disclosure:StrykerConsultingfeeConsulting
StevenCDronen,MD,FAAEMChair,DepartmentofEmergencyMedicine,LeConteMedicalCenter
StevenCDronen,MD,FAAEMisamemberofthefollowingmedicalsocieties:AmericanAcademyof
EmergencyMedicineandSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
GinoAFarina,MD,FACEP,FAAEMAssociateProfessorofClinicalEmergencyMedicine,AlbertEinstein
CollegeofMedicineProgramDirector,DepartmentofEmergencyMedicine,LongIslandJewishMedicalCenter
GinoAFarina,MD,FACEP,FAAEMisamemberofthefollowingmedicalsocieties:AmericanAcademyof
EmergencyMedicine,AmericanCollegeofEmergencyPhysicians,andSocietyforAcademicEmergency
Medicine
Disclosure:Nothingtodisclose.
HarrisGellman,MDConsultingSurgeon,BrowardHandCenterVoluntaryClinicalProfessorofOrthopedic
SurgeryandPlasticSurgery,DepartmentsofOrthopedicSurgeryandSurgery,UniversityofMiami,LeonardM
MillerSchoolofMedicine
HarrisGellman,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofMedicalAcupuncture,
AmericanAcademyofOrthopaedicSurgeons,AmericanOrthopaedicAssociation,AmericanSocietyforSurgery
oftheHand,andArkansasMedicalSociety
Disclosure:Nothingtodisclose.
JosephKaplan,MD,MS,FACEPAttendingPhysician,DepartmentofEmergencyMedicine,MartinArmy
CommunityHospital,FortBenning
JosephKaplan,MD,MS,FACEPisamemberofthefollowingmedicalsocieties:AmericanCollegeof
EmergencyPhysicians
Disclosure:Nothingtodisclose.
JeganKrishnan,MBBS,FRACS,PhDProfessor,Chair,DepartmentofOrthopedicSurgery,FlindersUniversity
ofSouthAustraliaSeniorClinicalDirectorofOrthopedicSurgery,RepatriationGeneralHospitalPrivate
Practice,OrthopaedicsSA,FlindersPrivateHospital
JeganKrishnan,MBBS,FRACS,PhD,isamemberofthefollowingmedicalsocieties:AustralianMedical
Association,AustralianOrthopaedicAssociation,andRoyalAustralasianCollegeofSurgeons

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GoutandPseudogoutClinicalPresentation:History,PhysicalExamination,Complications

Disclosure:Nothingtodisclose.
EdwardAMichelson,MDAssociateProfessor,ProgramDirector,DepartmentofEmergencyMedicine,
UniversityHospitalHealthSystemsofCleveland
EdwardAMichelson,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
Physicians,NationalAssociationofEMSPhysicians,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
SriyaKMRanatunga,MD,MPHAssociateProfessor,DepartmentofClinicalMedicine,SouthernIllinois
UniversitySchoolofMedicine
Disclosure:Nothingtodisclose.
HamptonRoySr,MDAssociateClinicalProfessor,DepartmentofOphthalmology,UniversityofArkansasfor
MedicalSciences
HamptonRoySr,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOphthalmology,
AmericanCollegeofSurgeons,andPanAmericanAssociationofOphthalmology
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment
RChristopherWalton,MDProfessor,DirectorofUveitisandOcularInflammatoryDiseaseService,Department
ofOphthalmology,AssistantDeanforGraduateMedicalEducation,UniversityofTennesseeCollegeof
MedicineConsultingStaff,RegionalMedicalCenter,MemphisVeteransAffairsMedicalCenter,StJude
Children'sResearchHospital
RChristopherWalton,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Ophthalmology,AmericanCollegeofHealthcareExecutives,AmericanUveitisSociety,AssociationforResearch
inVisionandOphthalmology,andRetinaSociety
Disclosure:Nothingtodisclose.

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