What are symptoms of gout?

The small joint at the base of the big toe is the most common site of an acute gout attack. Other joints that can be affected include the ankles, knees, wrists, fingers, and elbows. Acute gout attacks are characterized by a rapid onset of pain in the affected joint followed by warmth, swelling, reddish discoloration, and marked tenderness. Tenderness can be intense so that even a blanket touching the skin over the affected joint can be unbearable. Patients can develop fever with the acute gout attacks. These painful attacks usually subside in hours to days, with or without medication. In rare instances, an attack can last for weeks. Most patients with gout will experience repeated attacks of arthritis over the years.

Uric acid crystals can deposit in tiny fluid-filled sacs (bursae) around the joints. These urate crystals can incite inflammation in the bursae leading to pain and swelling around the joints, a condition called bursitis. In rare instances, gout leads to a more chronic type of joint inflammation which mimics rheumatoid arthritis.

In chronic (tophaceous) gout, nodular masses of uric acid crystals (tophi) deposit in different soft tissue areas of the body. Even though they are most commonly found as hard nodules around the fingers, at the tips of the elbows, and around the big toe, tophi nodules can appear anywhere in the body. They have been reported in unexpected areas such as in the ears, vocal cords, or (rarely) around the spinal cord!

How is gouty arthritis diagnosed?

Gout is suspected when a patient reports a history of repeated attacks of painful arthritis at the base of the toes. Ankles and knees are the next most commonly involved joints in gout. Gout usually attacks one joint at a time, while other arthritis conditions, such as systemic lupus and rheumatoid arthritis, usually attack multiple joints simultaneously.

The most reliable test for gout is finding uric acid crystals in the joint fluid obtained by joint aspiration (arthrocentesis). Arthrocentesis is a common office procedure performed under local anesthesia. Using sterile technique, fluid is withdrawn (aspirated) from the inflamed joint, using a syringe and needle. The joint fluid is then analyzed for uric acid crystals and for infection. Shiny, needle-like uric acid crystals are best viewed with a polarizing microscope. The diagnosis of gout can also be made by finding these urate crystals from material aspirated from tophi nodules and bursitis fluid.

Some patients with a classic history and symptoms of gout can be successfully treated and presumed to have gout without undergoing arthrocentesis. However, establishing a firm diagnosis is still preferable since other conditions can mimic gout. These include another crystal-induced arthritis called pseudogout, psoriatic arthritis, rheumatoid arthritis and even infection.

X-rays can sometimes be helpful, and may show tophi crystal deposits and bone damage as a result of repeated inflammations. X-rays can also be helpful for monitoring the effects of chronic gout on the joints.