Clinical features of acute gout

Rothenbacher, 2011Roughley, 2015Singh, 2011

The first acute attack of gout is usually monoarticular, and often occurs in the big toe (the first metatarsophalangeal joint) or another part of the foot. Symptoms manifest rapidly, often during the night or early morningChoi, 2015. The joint is usually very painful, red and swollen. The first attack can be severe and may mimic septic arthritis; patients may present with fever, malaise, leucocytosis, and elevated inflammatory markers. If the acute attack is not treated, symptoms usually subside over a few days to 1 to 2 weeks.

In females, the first attack may be polyarticular, typically in the hands and with gouty tophi. The presentation may be an acute inflammation in joints already affected by arthritis (eg the distal or proximal interphalangeal joints). Gout rather than a flare of osteoarthritis is suggested by the presence of tophi and an acute onset of inflammation (eg in an elderly female who may also be taking a diuretic).

Most patients who are not started on urate-lowering therapy will have a second acute attack of gout within 2 years. Ischaemic heart disease, hypertension and chronic kidney disease are independent risk factors for recurrent attacks. Recurrent attacks may be misdiagnosed as a sprain or other soft-tissue injury. Initially, recurrent attacks may be separated by long intervals of relatively normal joint function. Eventually, recurrent attacks occur more frequently, are of longer duration, and involve more joints.