Gout

Description

Alternative Names

Symptoms

Gout is often divided into four symptomatic stages:

• Asymptomatic hyperuricemia.
• Acute gouty arthritis.
• Intercritical gout.
• Chronic tophaceous gout.

These stages may differ depending on the age of onset:

• In middle-aged adults, symptoms are more likely to occur in one joint, most often in the lower limbs. About 60% of cases in this age group first occur in the big toe.
• In elderly people, symptoms are more likely to occur in a number of joints in the upper extremities, particularly the fingers.

Asymptomatic Hyperuricemia

Asymptomatic hyperuricemia, in which MSU slowly builds up, always precedes gout and is considered the first stage of the disorder. It lasts for an average of 30 years.

Note: Hyperuricemia does not inevitably lead to gout. In fact, less than 20% of the hyperuricemic population develops the full-blown arthritic disease.

Acute Gouty Arthritis

Acute gouty arthritis occurs when the first symptoms of gout appear. Sometimes gout is heralded by brief twinges of pain (petit attacks) in an affected joint, which can precede the actual full-blown condition by several years. MSU crystals form at normal body temperature when concentrations in the blood reach 7 mg/dL. At lower temperatures, crystals form at lower concentrations. Since blood temperature falls with distance from the heart, gout strikes the toes and fingers first.

The symptoms of acute gout arthritis are described as follows:

• The primary symptom is severe pain at and around the joint. Some patients describe it "crushing" or resembling a dislocated bone. The area can be so tender that walking and even the weight of bed sheets can be unbearable. One writer described gout in the toe as feeling like walking on my eyeballs. The pain usually takes eight to 12 hours to develop. In many cases the attack occurs late at night or early in the morning and may awaken the patient from sleep.
• Swelling may extend beyond the joint, indicating fluid build-up within.
• The skin over the affected area is often red, shiny, and tense. After a few days it may start to peel.
• Chills and mild fever, loss of appetite, and feelings of ill health may occur with an attack.

Most often symptoms first start in one joint, a condition is called monoarticular gout. If more than one joint is affected, it is known as polyarticular gout. (Multiple joints are affected in only 10% to 20% of first attacks.)

• Monoarticular Gout. The joint of the big toe is the site of about 60% of all first monoarticular gout attacks in middle-aged adults. This occurrence is known as podagra. (The site is medically referred to as the big toes metatarsophalangeal joint, the point where one of the five long bones of the foot meets the first digit of a toe.) Symptoms can also occur in other locations, although most often they develop somewhere on one lower limb in middle-aged men.
• Polyarticular Gout. Older people are more likely to have polyarticular gout. In this condition, the joints of the foot, ankle, knee, wrist, elbow, and hand are the most frequently affected. The pain usually occurs in joints on one side of the body and it is usually, although not always, in the lower extremities. People with polyarticular gout are more likely to have a more gradual onset of pain and a longer delay between attacks. Older people are at higher risk for polyarticular gout than younger adults and it tends to occur in the upper extremities, often in the fingers. People with polyarticular gout are also more likely to experience the low-grade fever, loss of appetite, and a general feeling of poor health.

An untreated attack will typically peak 24 to 48 hours after the initial appearance of symptoms, and subside after five to seven days, although it can last only hours to as long as several weeks.

Intercritical Gout

Intercritical gout is the term used to describe the periods between attacks. The first attack is usually followed by a complete remission of symptoms, but left untreated, gout nearly always recurs at some point in the future. One study reported that 62% of subjects experienced at least one further attack within a year. At the end of two years, 78% of patients experienced a recurrence. After 10 years, 93% of the patients had had repeat attacks.

Symptoms of Chronic Tophaceous Gout

Development of Chronic Pain. When gout remains untreated, the intercritical periods typically become shorter and shorter, and the attacks, although sometimes less intense, can last longer. Over the long term (about 10 to 20 years) gout becomes a chronic disorder characterized by constant low-grade pain and mild or acute inflammation. Gout may eventually affect several joints, including those that may have been free of symptoms at the first appearance of the disorder. In rare cases, the shoulders, hips, or spine are affected.

Symptoms of Tophi. Tophi, the knobby MSU crystal deposits that form during chronic gout, generally form in the following location:

• Helix of the outer ear (the curved ridge along the edge of the ear).
• Forearms.
• Elbow or knee.
• Hands or feet. (Older patients, particularly women, are more likely to have gout in the small joints of the fingers.)
• In rare cases, they can settle in regions around the heart and spine.

Tophi, generally, are painless. However, they can often cause pain and stiffness in the affected joint. Eventually, they can also erode cartilage and bone, ultimately destroying the joint. Large tophi under the skin of the hands and feet can give rise to extreme deformities.

Triggers for Gout Symptoms

Gout symptoms may be precipitated by various conditions including the following:

• Severe illness (an important trigger). Between 20% and 86% of patients with gout experience a recurrence when they are hospitalized. Gout accompanies and can be exacerbated by serious conditions that are associated with kidney and heart disease including diabetes, obesity, unhealthy cholesterol levels, insulin resistance, and high blood pressure.
• Stress.
• Infection.
• Joint injury.
• Weight loss.
• Surgery.
• Certain drug treatment (an important trigger).
• Overindulgence in alcohol or purine-rich foods.
• Overstrenuous exercise. Even a long walk can trigger symptoms in a patient who is not sufficiently physically fit.

Symptoms occur more frequently in the spring, with the peak in April, according to some studies.