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10/27/2015 Gout and Pseudogout Clinical Presentation: History, Physical Examination, Complications
http://emedicine.medscape.com/article/329958clinical 1/10
Gout and Pseudogout Clinical PresentationAuthor: Bruce M Rothschild, MD; Chief Editor: Herbert S Diamond, MD more...
Updated: Sep 21, 2015
HistoryThe spontaneous onset of excruciating pain, edema, and inflammation in themetatarsalphalangeal joint of the great toe (podagra; see the image below) ishighly suggestive of acute crystalinduced arthritis. Podagra is the initial jointmanifestation in 50% of gout cases; eventually, it is involved in 90% of cases.Podagra is not synonymous with gout, however: it may also be observed in patientswith pseudogout, sarcoidosis, gonococcal arthritis, psoriatic arthritis, and reactivearthritis.
Gout. Acute podagra due to gout in elderly man.
Other than the great toe, the most common sites of gouty arthritis are the instep,ankle, wrist, finger joints, and knee. In early gout, only 1 or 2 joints are usuallyinvolved. Consider the diagnosis in any patient with acute monoarticular arthritis ofany peripheral joint except the glenohumeral joint of the shoulder.
The most common sites of pseudogout arthritis are large joints, such as the knee,wrist, elbow, or ankle. Case reports have documented carpal tunnel syndrome as aninitial presentation of pseudogout. Case reports of calcium pyrophosphate (CPP)crystals forming masses in the spinal ligamentum flavum have been documented.[67] These have led to both singlelevel and multilevel myelopathy.
Although crystalinduced arthritis is most commonly monoarticular, polyarticularacute flares are not rare, and many different joints may be involved simultaneouslyor in rapid succession. Multiple joints in the same limb often are involved, as wheninflammation begins in the great toe and then progresses to involve the midfoot andankle.
Gout attacks begin abruptly and typically reach maximum intensity within 812hours. Affected joints are red, hot, and exquisitely tender; even a bed sheet on theswollen joint is uncomfortable. The onset of symptoms in pseudogout can resembleacute gout or be more insidious and may occur over several days.
Untreated, the first attacks resolve spontaneously in less than 2 weeks. A history ofintermittent inflammatory arthritis, in which the joints return to normal betweenattacks, is typical of crystalline disorders and is characteristic of gouty arthritis earlyin its course.
Gout initially presents as polyarticular arthritis in 10% of patients. Elderly women,particularly women with renal insufficiency who are taking a thiazide diuretic, candevelop polyarticular arthritis as the first manifestation of gout. These attacks mayoccur in coexisting Heberden and Bouchard nodes. Such patients may also developtophi more quickly, occasionally without prior episodes of acute gouty arthritis.[68, 69,70]
The pattern of symptoms in untreated gout changes over time. The attacks canbecome more polyarticular. More proximal and upperextremity joints becomeinvolved. Attacks tend to occur more frequently and last longer.
Eventually, patients may develop chronic polyarticular arthritis, sometimes nearlysymmetrical, that can resemble rheumatoid arthritis. Indeed, chronic polyarticulararthritis that began as an intermittent arthritis should prompt consideration of acrystalline disorder in the differential diagnosis.
Acute flares of gout can result from situations that lead to increased levels of serumuric acid, such as the consumption of beer or liquor, overconsumption of foods withhigh purine content, trauma, dehydration, or the use of medications that elevatelevels of uric acid. Acute flares of gout also can result from situations that lead todecreased levels of serum uric acid, such as the use of radiocontrast dye ormedications that lower the levels of uric acid, including allopurinol and uricosurics.
Patients with gout have as much as 1000 times more uric acid in the body asunaffected individuals do and are almost twice (1.97 times) as likely to developrenal stones as healthy individuals are[71] ; therefore, they may have a history ofrenal colic and hematuria. Indeed, renal stones may precede the onset of gout in
10/27/2015 Gout and Pseudogout Clinical Presentation: History, Physical Examination, Complications
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14% of affected patients. Whereas 52% of these patients may have stonescomposed entirely of uric acid, 20% may develop calcium oxalate or sometimescalcium phosphate stones.[72]
Because gout is frequently present in patients with the metabolic syndrome (eg,insulin resistance or diabetes, hypertension, hypertriglyceridemia, and low levels ofhighdensity lipoproteins) and because the presence of these associated disorderscan lead to coronary artery disease, these problems should be sought and treated inpatients diagnosed with gout.
It is important to ask about a history of peptic ulcer disease, renal disease, or otherconditions that may complicate the use of the medications used to treat gout.
Fever, chills, and malaise do not distinguish cellulitis or septic arthritis from crystalinduced arthritis, because all 3 illnesses can produce these signs and symptoms. Acareful history may uncover risk factors for cellulitis or septic arthritis, such aspossible exposure to gonorrhea, a recent puncture wound over the joint, or systemicsigns of disseminated infection.
Physical ExaminationPatients experiencing an acute attack of gout or pseudogout most often presentwith involvement of a single joint. However, all joints must be examined todetermine whether the patient’s arthritis is monoarticular or polyarticular. Involvedjoints have all the signs of inflammation: swelling, warmth, erythema, andtenderness.
The erythema over the joint may resemble cellulitis; the skin may desquamate asthe attack subsides. The joint capsule becomes quickly swollen, resulting in a lossof range of motion of the involved joint.
Patients may be febrile during an acute gout attack, particularly if it is polyarticular.However, it is important to look for sites of infection that may have seeded the jointand caused an infectious arthritis resembling or coexisting with acute gouty arthritis.
Migratory polyarthritis is a rare presentation. Polyarticular gout commonly involvesthe small joints of the fingers and toes, as well as the knees. An inflammatorysynovial effusion may be present. Uncommonly, acute gout may present as carpaltunnel syndrome.
Posterior interosseous nerve syndrome is a rare compression neuropathy thatmanifests as inability to extend the fingers actively. The syndrome has beenreported in a patient with elbow swelling from an attack of pseudogout; in this case,treatment with intraarticular steroids led to resolution of the nerve palsy.[73]
Patients with established gout may have chronic arthritis. Affected joints evidencetenderness and swelling, with or without redness, warmth, or joint damage.
Tophi
Although gout typically causes joint inflammation, it can also cause inflammation inother synovialbased structures, such as bursae and tendons. Tophi are collectionsof urate crystals in the soft tissues. They tend to develop after about a decade inuntreated patients who develop chronic gouty arthritis. Tophi may develop earlier inolder women, particularly those receiving diuretics.[68, 69, 70]
Tophi are classically located along the helix of the ear, but they can be found inmultiple locations, including the fingers, the toes, the prepatellar bursa, and alongthe olecranon, where they can resemble rheumatoid nodules (see the imagesbelow). Rarely, a creamy discharge may be present.[74, 75] The finding of anapparent rheumatoid nodule in a patient with a negative rheumatoid factor assay ora history of drainage from a nodule should prompt consideration of gout in thedifferential diagnosis.[76]
Gout. Tophaceous deposits in ear.
10/27/2015 Gout and Pseudogout Clinical Presentation: History, Physical Examination, Complications
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Gout. Tophaceous deposits on elbow.
Gout. Chronic tophaceous gout in untreated patient with endstage renal disease.
Eye involvement
The folklore surrounding gout has also involved the eye, and before the 20thcentury, a myriad of common and unusual ocular symptoms were falsely ascribed togout. Medical science has since documented eye involvement as a rare but definiteaspect of gout. All manifestations of gout in the eye are secondary to deposition ofurate crystals within the ocular tissue.[77, 78]
Tophi have been described in the eyelids.[79, 80, 81] Conjunctival nodules containingneedlelike crystals have been described within the interpalpebral areas, sometimesassociated with a mild marginal keratitis. Band keratopathy with refractile, yellowcrystals in the deep corneal epithelial cells and at the level of the Bowmanmembrane are not uncommon.[82]
Blurring of vision from the corneal haze or a foreign body sensation due to epithelialbreakdown may occur. Gout rarely can be associated with anterior uveitis; DukeElder mentions this as a cause of hemorrhagic iritis in his classic Text Book ofOphthalmology. Scleritis and tendinitis have also been described. Besides thecornea, the iris, anterior chamber, lens, and sclera have been found to harbor uratecrystals; on postmortem examination, urate crystals have also been found in tarsalcartilage and in the tendons of extraocular muscles.[77, 78]
ComplicationsComplications of gout include the following:
Severe degenerative arthritisSecondary infectionsUrate or uric acid nephropathyIncreased susceptibility to infectionUrate nephropathyRenal stonesNerve or spinal cord impingement [83, 84]
Fractures in joints with tophaceous gout [85]
Differential Diagnoses
Contributor Information and DisclosuresAuthorBruce M Rothschild, MD Professor of Medicine, Northeast Ohio Medical University; Adjunct Professor,Department of Biomedical Engineering, University of Akron; Research Associate, University of Kansas Museumof Natural History; Research Associate, Carnegie Museum
Bruce M Rothschild, MD is a member of the following medical societies: American Association for theAdvancement of Science, American College of Rheumatology, International Skeletal Society, New YorkAcademy of Sciences, Sigma Xi, Society of Skeletal Radiology
Disclosure: Nothing to disclose.
Coauthor(s)Mark L Francis, MD Professor of Medical Education, Department of Medical Education, Paul L Foster School ofMedicine, Texas Tech University Health Sciences Center
Mark L Francis, MD is a member of the following medical societies: American College of Physicians, Phi BetaKappa
10/27/2015 Gout and Pseudogout Clinical Presentation: History, Physical Examination, Complications
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Disclosure: Nothing to disclose.
Anne V Miller, MD Chief, Rheumatology Division; Assistant Professor of Internal Medicine, Department ofMedicine, Division of Rheumatology, Southern Illinois University School of Medicine
Anne V Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American College ofPhysicians, American College of Rheumatology, International Society for Clinical Densitometry
Disclosure: Nothing to disclose.
Chief EditorHerbert S Diamond, MD Visiting Professor of Medicine, Division of Rheumatology, State University of New YorkDownstate Medical Center; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital
Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American Collegeof Physicians, American College of Rheumatology, American Medical Association, Phi Beta Kappa
Disclosure: Nothing to disclose.
AcknowledgementsRichard W Allinson, MD Associate Professor, Department of Ophthalmology, Texas A&M University HealthScience Center; Senior Staff Ophthalmologist, Scott and White Clinic
Richard W Allinson, MD, is a member of the following medical societies: American Academy of Ophthalmology,American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.
Lawrence H Brent, MD Associate Professor of Medicine, Jefferson Medical College of Thomas JeffersonUniversity; Chair, Program Director, Department of Medicine, Division of Rheumatology, Albert Einstein MedicalCenter
Lawrence H Brent, MD is a member of the following medical societies: American Association for theAdvancement of Science, American Association of Immunologists, American College of Physicians, andAmerican College of Rheumatology
Disclosure: Abbott Honoraria Speaking and teaching; Centocor Consulting fee Consulting; GenentechGrant/research funds Other; HGS/GSK Honoraria Speaking and teaching; Omnicare Consulting fee Consulting;Pfizer Honoraria Speaking and teaching; Roche Speaking and teaching; Savient Honoraria Speaking andteaching; UCB Honoraria Speaking and teaching
Andrew A Dahl, MD Director of Ophthalmology Teaching, MidHudson Family Practice Institute, The Institutefor Family Health; Assistant Professor of Surgery (Ophthalmology), New York College of Medicine
Andrew A Dahl, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy ofOphthalmology, American College of Surgeons, American Medical Association, American Society of Cataractand Refractive Surgery, and Wilderness Medical Society
Disclosure: Nothing to disclose.
Paul E Di Cesare, MD, FACS Professor and Chair, Department of Orthopedic Sugery, University of California,Davis, School of Medicine
Paul E Di Cesare, MD, FACS is a member of the following medical societies: American Academy of OrthopaedicSurgeons, American College of Surgeons, and Sigma Xi
Disclosure: Stryker Consulting fee Consulting
Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy ofEmergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Gino A Farina, MD, FACEP, FAAEM Associate Professor of Clinical Emergency Medicine, Albert EinsteinCollege of Medicine; Program Director, Department of Emergency Medicine, Long Island Jewish Medical Center
Gino A Farina, MD, FACEP, FAAEM is a member of the following medical societies: American Academy ofEmergency Medicine, American College of Emergency Physicians, and Society for Academic EmergencyMedicine
Disclosure: Nothing to disclose.
Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of OrthopedicSurgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard MMiller School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture,American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgeryof the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.
Joseph Kaplan, MD, MS, FACEP Attending Physician, Department of Emergency Medicine, Martin ArmyCommunity Hospital, Fort Benning
Joseph Kaplan, MD, MS, FACEP is a member of the following medical societies: American College ofEmergency Physicians
Disclosure: Nothing to disclose.
Jegan Krishnan, MBBS, FRACS, PhD Professor, Chair, Department of Orthopedic Surgery, Flinders Universityof South Australia; Senior Clinical Director of Orthopedic Surgery, Repatriation General Hospital; PrivatePractice, Orthopaedics SA, Flinders Private Hospital
Jegan Krishnan, MBBS, FRACS, PhD, is a member of the following medical societies: Australian MedicalAssociation, Australian Orthopaedic Association, and Royal Australasian College of Surgeons
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Disclosure: Nothing to disclose.
Edward A Michelson, MD Associate Professor, Program Director, Department of Emergency Medicine,University Hospital Health Systems of Cleveland
Edward A Michelson, MD is a member of the following medical societies: American College of EmergencyPhysicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Sriya K M Ranatunga, MD, MPH Associate Professor, Department of Clinical Medicine, Southern IllinoisUniversity School of Medicine
Disclosure: Nothing to disclose.
Hampton Roy Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas forMedical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology,American College of Surgeons, and PanAmerican Association of Ophthalmology
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center Collegeof Pharmacy; EditorinChief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
R Christopher Walton, MD Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Departmentof Ophthalmology, Assistant Dean for Graduate Medical Education, University of Tennessee College ofMedicine; Consulting Staff, Regional Medical Center, Memphis Veterans Affairs Medical Center, St JudeChildren's Research Hospital
R Christopher Walton, MD is a member of the following medical societies: American Academy ofOphthalmology, American College of Healthcare Executives, American Uveitis Society, Association for Researchin Vision and Ophthalmology, and Retina Society
Disclosure: Nothing to disclose.
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