Gout: Clues To Clinical Diagnosis

Main Category: Gout
Article Date: 07 Jan 2009 - 5:00 PST

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Risk factors for gout include family history, older age, renal insufficiency, use of medications that reduce urate excretion, high intake of foods that increase urate production (beer, seafood, red meat, high-fructose beverages), and comorbidities such as obesity and metabolic syndrome.

About 90% of acute gout attacks are monoarticular; 50% occur in the first metatarsophalangeal joint. Pain, redness, and swelling peak in 1 day. Polyarticular involvement may suggest another condition. Sodium urate tophi typify chronic gout; they usually develop on the Achilles tendon, prepatellar bursa, olecranon bursa, or helix of the ear.

Characteristic symptoms and a high serum urate level support a presumptive diagnosis of gout. Synovial fluid analysis is indicated when empirical therapy fails. Radiographs generally are unhelpful in acute gout, but they may reveal erosions and sclerotic margins in chronic gout.

Acute gouty arthritis is frequently misdiagnosed or diagnosed late in its clinical course, and therapy is often suboptimal. Because the treatment of gout as a chronic, progressive disease has not been standardized, optimal disease management remains a challenge.

My goal here is to help you improve your ability to accurately diagnose gout. I discuss when and how to make a presumptive diagnosis, indications for joint aspiration, and which diagnoses to consider in the differential. In a second article in a coming issue, I will outline the keys to effective treatment.

GARY E. RUOFF, MD

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