Unusual Clinical Presentations of Gout

Tony C. Ning; Robert T. Keenan

Disclosures

Curr Opin Rheumatol. 2010;22(2):181 

In This Article

Abstract and Introduction

Abstract

Purpose of review The dogmatic description of gout is described as an inflammatory crystal-induced arthropathy that afflicts peripheral joints. This manuscript describes many recent cases and unusual clinical presentations of gout. Emphasis is placed on the ability of gout to cause diagnostic dilemmas that can impact patient treatment and care.
Recent findings Various genetic mutations can predispose patients in developing early onset gout. Environmental exposures, medications, and certain patient populations can affect pathophysiology of uric acid, predisposing patients both typical and atypical manifestations of gout. Numerous reports have described gout deposition in unusual parts of the body, which can mimic unrelated disease processes.
Summary Although classic gout is still most commonly seen, the disease can manifest as with a wide array of presentations. It is likely that such atypical presentations are a result of a complexity of reasons. When presented with a diagnostic challenge in a patient with gout, the clinician should be aware of unusual manifestations of gout and consider it in the differential.

Introduction

Gout is the most common inflammatory arthritis, with more than three million sufferers in the United States alone.[1,2••] The incidence and prevalence of gout are increasing worldwide.[3–5] The prevalence of gout increases with age, ranging from approximately 17 per 1000 among those 45–64 years of age, to as high as 41 per 1000 in those 75 years of age and older.[5] Risk factors associated with the increase in gout include: longevity, a subsequent rise in the prevalence of comorbid conditions, and dietary and lifestyle changes. Patients with the metabolic syndrome (obesity, hypertension, increased lipids, insulin resistance) are at increased risk in developing cardiovascular disease, diabetes, hyperuricemia, and gout.[5]

The initial gouty attack typically follows years of asymptomatic hyperuricemia and subsequent crystallization of urate as a monosodium salt in a joint inciting inflammation.[6] The classic description of an acute gouty attack is heralded by the rapid onset of color, dolor, rubor, et tumor of the joint and surrounding soft tissue. The famous 17th-century physician Thomas Sydenham wrote on his own experiences with gout.[7] He likened the pain of the acute attack to that of a dog gnawing on the joint. The initial attack is monoarticular in the vast majority of cases, and involves the first metatarsophalangeal (MTP) joint in approximately 50% of cases. The MTP is eventually affected in 90% of individuals with gout.[7] The majority of the cases usually involve a single joint in the lower extremities, typically the first MTP joint or the knee.

Although the classic description of gouty arthritis includes the first MTP, the knee, the ankle or maybe even the distal interphalangeal (DIP) joint, this is not always the case. Given the increasing incidence and prevalence of gout, coupled with the improvement and rising use of various-imaging modalities, it stands that gout is not just limited to that classic description that Dr Sydenham so eloquently described.

There have been an increasing number of cases reported in the literature that demonstrate that gout can truly affect almost any part of the body. In many of these cases, diagnostic uncertainty was present; and the presence of gout was determined incidentally by pathological, surgical, and radiographical findings. Unusual clinical presentations of gout can range from atypical disease progression from one patient population to another, to symptomatic-tophaceous deposits in atypical sites within the body. Such seemingly unconventional presentations can lead to inaccurate diagnoses and delays in treatment, requiring the investigator to think outside the dogmatic clinical description of gout.

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