"Be temperate in wine, in
eating, girls, and sloth, or the
Gout will seize you and
Galen (129-199 AD), an ex-gladiatorial
surgeon in the Pergamon arena in Asia
Minor who moved to Rome, described gout
as a discharge of the four humors of the
body in unbalanced amounts into the joints
(hence gout = gutta, a drop).
The first radiological description of gout
was made by Huber in 1896, a few months
after Röentgen described the x-ray.
Uric acid: overproduction vs.
Mechanisms of urate “production”
cellular nucleoproteins/nucleotides (~ 66%)
Mechanisms of urate excretion
Completely filtered by the glomerulus
Completely (essentially) reabsorbed in the
Approximately 50% is secreted back into the
tubule in the descending loop
Approximately 80% (of the 50% now in the
loop) is reabsorbed in the ascending loop
Net excretion = 10% of filtered load
Hyperuricemia alone does NOT make a
diagnosis of gout
-only a subset of people with hyperuricemia will
-probability of gout increases with higher uric
Asymptomatic hyperuricemia generally
requires no treatment
Hyperuricemia (>7.0 mg/dl) in 5% - 8% of
Most (about ⅔) are forever asymptomatic.
80% of gouty patients have uric acid < 9
Above 10 mg/dl, risk rises rapidly.
Gout is the most common cause of
monarthritis in middle-aged and elderly men
(8% yearly prevalence).
Lasts several days to several weeks.
May spread from joint to joint.
Often accompanied by fever,
Gets worse as the years go on.
Pain appears last, disappears first.
Petite attacks occur (lasting hours).
First attack 4th-6th decade for men
Women almost always postmenopausal
Classically monoarticular LE– podagra
(50%), (vs pseudopodogra) >ankle
>gonagra >upper extremity.
Proximal joint, central arthropathy
Evidence-based medicine based on EULAR
(ESCISIT) – 10 key points
Acute attack 6-12 peak intensity with S/W/E/T
Aspiration always recommended if possible
Prompt polarized microscopic analysis performed
Definitive Dx – requires crystal confirmation
Gout and Sepsis can coexist – fluid should be sent Gram’s
Serum uric acid levels neither confirm nor exclude gout
Radiographs not necessary
Risk factor assessment
biochemical hallmark of gout, but not by itself
diagnostic for gout
leukocyte counts = septic arthritis
viscosity is < septic or inflammatory arthritis
MSU needle - like intracellular & extracellular
Negatively birefringent crystals under polarized light
THERAPY (for all crystal diseases):
Corticosteroids: intrarticular > systemic
NSAIDs – fast acting full dose if no
Colchicine (PO,IV route dangerous)
▪ narrow therapeutic window
▪ Bone marrow suppression, myopathy, neuropathy
▪ purgative effects – “Pt often run before they walk”
70% prevelance of MSU crystals remain in the
Lasts months to years for 75-80%, 20% never
have another attack
Lifestyle, dietary modification
Diet high in vegetables, dairy, water
Initiate uric acid lowering therapy after 1(?)
or 2 episodes of acute gouty arthritis
Always prophylaxis for first 6 months with
low dose steroids, NSAIDs, or colchicine
USUALLY PRESENT AFTER 10YEARS OF
CHRONIC SWOLLEN JOINTS
ABSOLUTELY REQUIRES ALLOPURINOL
Punched out lesions with sclerotic borders.
Preservation of joint space (till late)
The “Double Contour Sign” of Gout.
Filippucci E, Grassi W
Department of Rheumatology, University of Ancona, Italy
hallux, ankle, knee, hand
knee, wrist, ankle
Almost any joint can be affected by either
Acute arthritis caused by Calcium pyrophosphate
dihydrate (CPPD) crystal-induced inflammation
May perfectly mimic gout during acute flare
Attacks occurring before age 50 are uncommon
Most often affects the knee and the wrists
Calcification densities in hyaline or fibrocartilage,
which are found in knee menisci, acetabular labrum,
CPPD crystals are visualized under compensated polarized
crystals may be more difficult to detect than MSU crystals
because of their smaller size, more intralysosomal
location, & less brilliant colors
CPPD crystals show weak positive birefringency and have
squared or rhomboidal shaped ends
alizarin red stain, can confirm that these clumps are
masses of calcium crystals
aspiration of the involved joint and steroid injection,
once diagnosis of infection has been excluded, will
usually control symptoms
Is usually a peri-arthritis.
Intense inflammation (looks septic)
Synovial fluid often non-inflammatory.
Often causes podagra (especially in
Look for the telltale calcifications on
Severe, destructive shoulder arthropathy.
Seen in elderly females with DJD of
High-riding humeral head on radiographs
(large rotator cuff tear).
Non-inflammatory fluid with BCP crystals.
Is an association of acute cervical pain and
calcifications in the peri-odontoid space.
This disease affects only adult females.
Patients present with inflammatory signs,
can be treated with non-steroid anti-
inflammatory drugs and recover without
CPPD deposition can also lead to this
Radiologically - crowned dens.