From the Guidelines
A patient with pain and swelling in the L 1st toe and ankle can still have gout despite negative X-ray and CT foot findings, as gout is primarily diagnosed clinically and imaging studies may not show characteristic changes early in the disease or during an acute attack. Gout diagnosis is based on the identification of monosodium urate crystals in synovial fluid through joint aspiration and polarized light microscopy, which is the gold standard for diagnosis 1. Clinical features highly suggestive of gout include rapid onset of severe pain, erythema, and swelling, particularly in the first metatarsophalangeal joint (podagra), with symptoms peaking within 24 hours and resolving within 1-2 weeks even without treatment. According to the 2018 updated European League Against Rheumatism evidence-based recommendations for the diagnosis of gout, a clinical diagnosis of gout is supported by suggestive features such as monoarticular involvement of a foot or ankle joint, previous similar acute arthritis episodes, and associated cardiovascular diseases and hyperuricaemia 1.
Key Points to Consider
- The diagnosis of gout should not be made on the presence of hyperuricaemia alone, as recommended by the European League Against Rheumatism 1.
- Synovial fluid aspiration and examination for crystals is strongly recommended in any patient with undiagnosed inflammatory arthritis, with a level of evidence of 3 and a grade of recommendation of C 1.
- Imaging studies, such as ultrasound scanning, can be helpful in establishing a diagnosis in patients with suspected gout flare or chronic gouty arthritis by detection of tophi or a double contour sign at cartilage surfaces, which is highly specific for urate deposits in joints 1.
- Risk factors for chronic hyperuricaemia, such as chronic kidney disease, overweight, and consumption of excess alcohol, should be searched for in every person with gout 1.
Recommendations for Diagnosis and Treatment
- Synovial fluid analysis is recommended when clinical judgment indicates that diagnostic testing is necessary in patients with possible acute gout, as stated by the American College of Physicians 1.
- If gout is suspected despite negative imaging, treatment with colchicine, NSAIDs, or corticosteroids can be initiated, and the diagnosis can be further evaluated through joint aspiration or by assessing response to therapy.
- Systematic assessment for the presence of associated comorbidities in people with gout is recommended, including obesity, renal impairment, hypertension, ischaemic heart disease, heart failure, diabetes, and dyslipidaemia, with a level of evidence of 1a and a grade of recommendation of A 1.
From the Research
Diagnosis of Gout
- Gout is characterized by swelling, pain, or tenderness in a peripheral joint or bursa, including the development of a tophus 2
- Diagnosis of gout can be made using several validated clinical prediction rules 2
- Arthrocentesis should be performed when suspicion for an underlying septic joint is present; synovial fluid or tophus analysis should be performed if the diagnosis is uncertain 2
Imaging Studies
- A negative X-ray (XR) and computed tomography (CT) scan do not rule out gout, as gout is caused by monosodium urate crystal deposition in joints and tissues, which may not be visible on imaging studies 2, 3
Clinical Presentation
- Gout can present with pain and swelling in a joint, such as the 1st toe and ankle 2, 4
- The presence of pain and swelling in the 1st toe and ankle, even with a negative XR and CT scan, does not exclude the diagnosis of gout 2, 3
Treatment and Management
- Colchicine, nonsteroidal anti-inflammatory drugs, and corticosteroids relieve pain in adults with acute gout episodes 2, 5
- Urate-lowering therapies, such as allopurinol and febuxostat, aim to prevent gout flares and are used in the long-term management of gout 2, 3, 4
- Low-dose colchicine may be an effective treatment for acute gout and can prevent gout flares with fewer adverse events compared to regular-dose colchicine 5, 6