Gout

The gold standard for diagnosis is joint aspiration and synovial fluid analysis; however, compensated polarized light microscopy is not available in most primary care practices. In part 2 of his 3-part podcast, Dr Lieberman discusses the diagnosis of gout in real-world practice.

Gout is a primary care disease. About 70% of patients with gout are treated exclusively in the primary care setting. And because the prevalence of gout is increasing, particularly in older patients, you are increasingly likely to encounter this disease in your practice.

These joint deformities occurred in a 61-year-old man with chronic tophaceous gout. The patient had had joint pain and swelling since he was 40 years old; the symptoms began in 2 fingers and were initially mild. He did not seek medical attention. Within 5 to 10 years, joint abnormalities had developed in the fingers and then in the left elbow and right ankle. The toes were not affected. He had no family history of joint pain or swelling. Serum uric acid level was 9.7 mg/dL.

Although gout has been recognized since ancient times, its management remains challenging. In a previous article (CONSULTANT, December 2008, page 1010), I focused on diagnosis; here I discuss how the treatment approaches for an acute flare and for chronic gout differ, and I compare the safety and efficacy of available therapies.

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.

BOSTON, May 25 -- At relatively high daily doses, coffee -- whether regular or decaf -- may protect against gout, researchers here found.

A 49-year-old man complains of sharp pain in the medial left ankle that begansuddenly 3 nights earlier, waking him up. That night he also felt feverish anddiaphoretic, but those symptoms have subsided. The pain is present whenhe moves the ankle or when a shoe compresses the area. No other joints areinvolved. He denies trauma to the ankle or foot.

Allopurinol has been usedto treat gout for well over3 decades. In addition,this drug is prescribed toprevent urate nephropathyin patients who are receiving cancerchemotherapy.

Allopurinol, commonly used to treat patients with gout, has been known to cause hypersensitivity reactions. We report a case of drug-induced delayed multiorgan hypersensitivity syndrome secondary to allopurinol use. To the best of our knowledge, this is the first reported case of diffuse alveolar hemorrhage in a patient presenting with allopurinol-induced rash with eosinophilia and systemic symptoms.

For 2 days, a 60-year-old man with a history of gout had excruciating pain in the left big toe. During 2 previous episodes, colchicine had relieved his symptoms. On this occasion, colchicine failed to provide relief. The patient's first metatarsophalangeal joint of the left foot was erythematous, hot, and tender. He could not bear weight on the foot. Other physical examination findings were normal.

Since gout can precipitate olecranon bursitis, should I routinely order a crystalanalysis for patients who present with this bursitis?

Six months ago, I prescribed allopurinol for a patient with a history of podagra, several tophi in one toe, and an elevated uric acid level.

A 73-year-old man was admitted to the hospital with pain in his hands, feet, and elbows. The patient, an alcoholic, had a 20-year history of hypertension and diabetes. Deformities of the hands and feet had developed during the past 5 years. Tophi were present over both ear lobes. The serum uric acid level was 15 mg/dL.

A 65-year-old man had a 10-year history of deformity of the hands, pain, and nodules on the fingers. His serum uric acid level was 9 mg/dL. The suspected diagnosis of chronic tophaceous gout was confirmed by the finding of birefringent monosodium urate needle-shaped crystals in the joint fluid and the patient's significant response to colchicine within 12 to 24 hours of the start of therapy.

An 80-year-old man, who could not walk because of a large mass on his right leg, was brought to the emergency department. The mass had been increasing in size on the anterior region of his right thigh for approximately 6 months. The patient also complained of “lumps” that had developed on his extremities during the past 2 months.

A 56-year-old man who consumed moderate amounts of alcohol was awakened by an intense burning pain in the right great toe; local erythema and edema were also present. Within hours, the pain became excruciating, and the same symptoms developed in the left great toe. Acetaminophen provided no relief. The patient's serum uric acid level was 8.8 mg/dL.

A 5-day history of pain and swelling in the right third finger (A) were the complaints of a 76-year-old man. A few days earlier, another physician had prescribed indomethacin, 25 mg tid, but it had not helped, and the patient believed that his condition had worsened. He had had an attack of gout 5 years before but had not been taking any maintenance medication. The distal interphalangeal (DIP) joint of the affected finger was now erythematous and tender, with chalky subcutaneous deposits. A diagnosis of acute gouty arthritis and gouty tophus was made.

For 2 years, a 79-year-old man had postprandial fullness and epigastric discomfort. He also experienced regurgitation and substernal pain after eating that was relieved by belching. He had a history of hypertension and gout. The patient’s vital signs were normal. Laboratory test results were within normal limits.

For 2 years, a 79-year-old man had postprandial fullness and epigastric discomfort. He also experienced regurgitation and substernal pain after eating that was relieved by belching. He had a history of hypertension and gout. The patient’s vital signs were normal.

For several months, a 49-year-old woman has had asymptomatic loss of pigmenton her shins. She has no history of injury to the area.What is your clinical impression?

A 33-year-old man presented with joint pain and general malaise of about 2 weeks' duration and small yellowish lesions on the pinnae of the ears of about 6 months' duration. He had no urinary symptoms or conjunctivitis and was not taking any medications. His grandfather had been treated for gout.

A 54-year-old man is admitted to the hospital because of worsening lower extremityswelling and knee and ankle pain and stiffness. These symptoms havemade walking very difficult for the past month.

A 50-year-old manpresents to your office with severediscomfort in the great toe that began24 hours earlier. He denies any traumabut says that he may have hadsimilar symptoms many years before.He has no recent history of feveror illness. You aspirate fluid from thefirst metatarsophalangeal joint foranalysis.

Can cyclooxygenase (COX)-2 inhibitorsbe used to treat gout?