The stages of gout
Gout is a progressive and chronic disease with three stages. Asymptomatic hyperuricemia, which is often discovered through an incidental lab finding, begins the process. This is a relatively long period during which crystals begin to form and slowly accumulate in joints and soft tissue. The Normative Aging Study found that the higher the initial serum urate level in men with asymptomatic hyperuricemia, the greater the chance of a first acute flare.8 It is not usually necessary to directly address this condition unless the serum urate is extremely high or it is detected in a young person.
In the second stage, known as intermittent gout, patients present with recurring flares of acute inflammatory monoarthritis, which primarily affects the lower extremities. The great toe (Figure 1), ankle, or knee suddenly develops moderate-to-severe pain, warmth, and swelling. The great toe is affected in more than half the initial attacks of gout. Gout does not have to be articular, however. The olecranon bursa and Achilles tendon are well recognized nonarticular sites.
Several factors set the stage for a gout attack. In addition to hyperuricemia, common inciters include acute illnesses (especially surgery), trauma to a joint, worsening of degenerative arthritis, excessive alcohol consumption (particularly beer), and new medication with an effect on serum urate concentrations (thiazide diuretics are often a culprit).
A typical gout attack lasts less than one week if untreated. However, the pain is intense, and patients often present to the emergency department (ED) rather then wait to arrange an office visit. Some very elderly patients may have a less severe presentation.
It’s important to sort through the differential diagnosis of acute monoarthritis. While busy clinicians frequently do not have the time to perform arthrocentesis, hot joints should be tapped. The fluid obtained should be cultured and examined for crystals. Urate crystals observed in the synovial fluid aspirate is still the gold standard for making the diagnosis of gout.
There are usually no sequelae from an acute gout attack. A fortunate 5%-10% of patients suffer only one episode, but most go on to have recurrent episodes in which the time between flares shortens.
Even during the flare-free period, hyperuricemia is present. Urate crystals continue to form and can be found in joints, setting the stage for a gout flare.
The number of persons who go on to the third phase, chronic gout, is uncertain and likely relates to how well the underlying hyperuricemia is controlled. In this stage, chronic arthritis (often polyarticular) is the major manifestation. Flares continue but are superimposed on a background of daily arthritis discomfort. Masses of urate crystals, known as tophi, are seen in soft tissue. Tophi favor the peri-articular regions, especially the elbow and small joints of the hand. The Achilles tendon and helix of the ear are other common sites for tophi.
In the early stages of gout, sensitive imaging, such as MRI, reveals hidden damage to joints. In later-stage disease, bone and joint abnormalities are apparent on plain x-rays. Tophi are often painful and destructive, causing deformities to the joints over time.