Gout is a painful arthritic condition that can affect any joint, but commonly involves the joint at the base of the great toe (See Figure 1). Gout occurs when uric acid (normally present in the blood) crystallizes in the lining of the involved joint. These urate crystals incite an intense inflammatory reaction that often creates marked pain and swelling. Risk factors for gout include elevated blood uric acid levels, combined with an increased acidity in the bloodstream. Initial treatment is aimed at decreasing symptoms and may include the use of anti-inflammatory medications, rest, and ice. Long-term management is oriented towards preventing recurrent attacks and limiting the long-term effects that gout may have on the involved joint.
Patients often report a relatively sudden onset of severe symptoms including pain, swelling, and redness. Gout may involve almost any joint in the body, but in about 75% of first attacks it affects the joint at the base of the big toe (Podagra), and less commonly it affects the ankle. Acute episodes of gout are usually associated with elevated blood levels of uric acid and increased acidity of the bloodstream, and therefore the following have been known to increase the risk of gout attacks in susceptible individuals:
The diagnosis of gout is initially based on the patient’s symptoms. An initial treatment can be started based on the patient’s symptoms. Elevated blood uric acid levels will further support the diagnosis. The diagnosis of gout is confirmed by removing fluid from the affected joint (“tapping” or “aspirating” the joint) and looking at it under the microscope. Elongated rods of uric acid crystals will be seen when viewed under the microscope with polarized light.
X-rays are likely to be normal, except after multiple attacks or if there are other problems in the joint, such as hallux rigidus in the great toe. In patients who have suffered from gout over a long period of time, crystal collections (called “tophi”) may reach a size where they can be seen on x-rays. X-rays can be helpful to rule out other conditions that may cause similar symptoms, such as fractures, severe osteoarthritis, charcot athropathy, infection, or pseudogout. MRI is usually not indicated in making the diagnosis of gout.
The initial treatment of a gout attack is aimed at reducing the pain, which can be quite severe. After the initial symptoms have been resolved, long-term management of gout focuses on minimizing the risk of future attacks of gout.
A variety of treatment approaches have been recommended to minimize the risk of recurrent gout attacks including: