Unusual Clinical Presentations of Gout

Tony C. Ning; Robert T. Keenan


Curr Opin Rheumatol. 2010;22(2):181 

In This Article


Dr Sydenham's description of being awakened by a severe pain in a hot, red, and swollen great toe is the classic presentation and almost pathognomonic for our society's most common inflammatory arthropathy. Although most think of gout in its classic form, it can have a broad spectrum of clinical manifestations. Gout can manifest as tophi on a large number of organs, coexist with soft-tissue tumors, or even mimic disease processes that have very different pathophysiology.

Approaching gout with a new perspective, especially in light of such unusual presentations, raises several questions and potentially ambiguous answers. The obvious are, why and how does gout, an inflammatory disease of peripheral joints, manifest in places outside peripheral joints? One possible explanation is that these unusual manifestations may not be so unusual after all. Arguably, the incidence may have only increased due to bias secondary to advances in testing and imaging techniques. For example, the diagnosis of axial involvement seems to have been under recognized. A retrospective study done by Konatalapalli et al.[41•] had reviewed patients who had crystal proven gout, with CT scan done of their spine for other various medical reasons. After examining the CT scans for the qualifying patients, a total of nine out of 64 patients had radiographical signs consistent with gout. As in previous reports, the involvement had a predilection for the lumbar spine and some thoracic involvement also seen.

Another explanation of such unusual cases may due to a rise in gouty disease burden. The reasons for an increased burden are likely complex, but may have roots in our current milieu of fructose-laden diets, metabolic syndrome, and an aging population. High fructose-corn syrup as been hypothesized by some to contribute not only to obesity, but also to hyperuricemia, and subsequent gout.[65] The association between both the rising prevalence of gout and the metabolic syndrome has been well described and likely contributes to the complexity.[66,67] In addition, as the population gets older, the body and its immune system may become more susceptible to gout's havoc.


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