MANUAL MINORS
An acute gout attack is a form of arthritis that occurs when monosodium urate crystals accumulate in a joint, triggering intense inflammation, sudden pain, and redness.
This type of arthritis commonly affects the big toe joint (podagra), though it can also involve other joints. It is associated with elevated blood uric acid levels (hyperuricaemia) and can be triggered by factors such as a purine-rich diet, alcohol consumption, dehydration, or trauma.
Diagnosis
The diagnosis is based on the clinical presentation of sudden, severe, localised joint pain, accompanied by swelling, warmth, and erythema in the affected joint. It is confirmed by joint aspiration (arthrocentesis), where synovial fluid analysis reveals negatively birefringent urate crystals under polarised light. Blood uric acid levels are typically elevated, though they may be normal during an acute attack.
Differential Diagnosis
Condition | Distinctive Features |
|---|---|
Septic arthritis | Severe pain, fever, synovial fluid showing leukocytosis and positive culture, history of prior infection. |
Pseudogout (chondrocalcinosis) | Presence of calcium pyrophosphate crystals in synovial fluid, commonly affecting knees and wrists. |
Rheumatoid arthritis | Affects multiple joints symmetrically, positive serological tests (RF, anti-CCP). |
Osteoarthritis | Progressive chronic pain, no acute event, associated with degenerative changes on X-rays. |
Cellulitis | Diffuse inflammation and erythema, no direct joint involvement, absence of crystals in synovial analysis. |
Emergency Management
In an acute gout attack, emergency management focuses on relieving pain and inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as indomethacin or naproxen, are administered in high doses, as well as colchicine, or in severe cases, systemic or intra-articular corticosteroids.
Immobilisation and elevation of the affected joint, along with the application of local ice, help reduce inflammation. If the diagnosis is uncertain, arthrocentesis may be performed to rule out infection.
Definitive Treatment
Definitive treatment involves long-term control of uric acid levels to prevent future attacks. This includes dietary modification (avoiding purine-rich foods such as red meat and seafood), reducing alcohol intake, and the use of uricosuric drugs or xanthine oxidase inhibitors, such as allopurinol or febuxostat, to lower blood uric acid levels.
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