Since gout is a kind of arthritis, it hurts and impairs the joints. The abrupt onset of intense pain, swelling, warmth, and redness of a joint are the hallmarks of a typical gout attack. A bacterial infection is one of the rare mimics of acute gouty arthritis’s less modest clinical appearance.
The first metatarsophalangeal joint, or podagra, in the big toe, is the joint that is most frequently affected by gout. A gout attack (and there may be more than one) can affect any joint, although the feet, ankles, knees, and elbows are the most common locations.
Even without therapy, an acute gout attack typically peaks 12 to 24 hours after it starts and then slowly starts to subside. Without therapy, a gout attack usually requires 7 to 14 days to fully recover from.
Dr. Thomas Sydenham, who had gout himself, neatly penned a realistic and vivid description of a gout episode in 1683:
The individual goes to sleep and wakes up feeling well. A strong pain in the great toe, or less frequently in the heel, ankle, or instep, awakens him around two in the morning. The components feel as though cold water has been poured over them, but the discomfort is similar to that of a dislocation. Then comes shivering, chills, and a slight temperature. The little ache that was initially experienced intensifies. The shakes and chills get worse as it gets stronger. This gradually reaches its full height and conforms to the tarsal and metatarsal bones and ligaments. Now the ligaments are being violently stretched and torn, and the pain is gnawing, pressing, and tightening. The affected part’s sensation is so delicate and vibrant that it is unable to support the weight of the sheets or the jar of a visitor entering the room.
Asymptomatic Hyperuricemia
Although nearly all gout patients have hyperuricemia (high levels of uric acid in the blood), it is vital to understand that.
Not all people with hyperuricemia have gout. There is currently no advice for treatment during this time in the absence of clinical signs or symptoms of gout, despite the fact that the majority of people will have elevated levels of uric acid in the blood for several years prior to experiencing their first gout attack. This condition is known as “asymptomatic hyperuricemia.” Increasing uric acid levels increase the chance of a gout attack, however many people will experience attacks even with “normal” uric acid levels, and some patients will never experience an attack while having extremely high uric acid levels.
Chronic Tophaceous Gout
Some people only have acute gout attacks, which may occur just once or twice a year (or even 1-2 times in lifetime). Gout, however, can be a persistent, relapsing condition for some people, with repeated, severe attacks occurring at frequent intervals and with incomplete clearance of inflammation between attacks. Chronic gout, a type of gout that can seriously damage joints and deform them, is sometimes mistaken for other types of chronic inflammatory arthritis, like rheumatoid arthritis. Uric acid tophi, which are solid deposits of uric acid under the skin, are frequently found and aid in the degeneration of bone and cartilage. For chronic tophaceous gout, tophi are diagnostic. Tophi can be discovered near the pinna of the ear, in the olecranon bursa, or around joints. Tophi can be dissolved with treatment and will eventually go entirely.
Diagnosis of Gout
A tophaceous deposit or the observation of uric acid crystals in synovial fluid might be used to confirm a gout diagnosis. A conclusive diagnostic finding of needle-shaped negatively-birefringent uric acid crystals can be made in the presence of an acute gout attack by aspirating joint fluid (drawing fluid out of the swollen joint with a needle) and examining the fluid under polarized light (yellow when parallel to the axis of polarization). During an acute attack, neutrophils often contain intracellular crystals.
In these situations, arthrocentesis is essential to rule out infection by sending the joint fluid for culture because the clinical characteristics of acute gout and a septic joint (bacterial infection) might be quite similar. Importantly, even in patients with a known history of gout, sending joint fluid for culture should be considered if they are at risk for infection because gout and infection can co-exist in the same joint (they are not mutually exclusive).
To confirm a diagnosis of chronic tophaceous gout, tophi can be aspirated or the tophaceous material expressed and studied using polarized microscopy.
Although the presence of hyperuricemia or normal serum uric acid levels alone does not establish or disprove the diagnosis of gout, it is commonly the case that uric acid levels are normal during an acute gout episode.
