Can gout cause fever?

Gout Can Cause Fever

Yes, gout can cause fever as part of the acute inflammatory response to monosodium urate crystal deposition in joints. 1

Pathophysiology of Fever in Gout

Gout is characterized by the deposition of monosodium urate crystals in joints and soft tissues, triggering an intense inflammatory cascade. This inflammatory process can lead to systemic symptoms including:

• Fever (often low-grade)
• Malaise
• Elevated inflammatory markers

The inflammatory response in gout involves:

1. Activation of the NLRP3 inflammasome when macrophages encounter urate crystals 2
2. Release of pro-inflammatory cytokines, particularly IL-1β
3. Recruitment of neutrophils to the affected joint
4. Systemic inflammatory response that can manifest as fever

Clinical Presentation

Acute gout attacks typically present with:

• Sudden onset of severe joint pain (often in the first metatarsophalangeal joint)
• Swelling and erythema of the affected joint
• Warmth over the joint
• Fever - particularly in severe attacks or polyarticular gout
• Elevated inflammatory markers (ESR, CRP)

Management Implications

When fever is present with suspected gout:

1. Rule out septic arthritis - This is critical as both conditions can present with fever and joint inflammation. Arthrocentesis should be performed when suspicion for septic arthritis exists 3

2. Treatment options - The American College of Physicians strongly recommends:

   • Corticosteroids
   • NSAIDs (such as indomethacin)
   • Colchicine

   All these treatments effectively reduce both joint inflammation and associated fever 1

3. First-line preference - Corticosteroids should be considered first-line therapy in patients without contraindications as they are generally safer and cost-effective 1

Important Clinical Considerations

• Fever in gout is typically low-grade but can occasionally be more pronounced in severe attacks
• The presence of high fever (>38.5°C/101.3°F) should raise suspicion for alternative or concomitant diagnoses
• Elderly patients with gout may have blunted fever response despite significant inflammation
• Comorbidities common in gout patients (diabetes, chronic kidney disease, heart failure) may affect both presentation and treatment choices 4

Treatment Algorithm for Gout with Fever

1. For mild-moderate fever with typical gout presentation:

   • Treat with standard gout therapies (corticosteroids, NSAIDs, or colchicine)
   • Acetaminophen can be added specifically for fever control

2. For high fever or atypical presentation:

   • Perform joint aspiration to rule out infection
   • Consider broader antibiotic coverage until infection is excluded
   • Proceed with gout treatment once infection is ruled out

3. For patients with recurrent gout and fever:

   • Consider urate-lowering therapy to prevent future attacks
   • Target serum urate levels below 6.0 mg/dL (or below 5.0 mg/dL in tophaceous gout)

Pitfalls to Avoid

• Don't assume all joint pain with fever is septic arthritis
• Don't dismiss the possibility of gout because of fever
• Don't forget that gout and septic arthritis can coexist
• Don't delay appropriate treatment while waiting for crystal confirmation if clinical suspicion for gout is high

Remember that while fever can occur in gout, its presence, especially if high-grade, should prompt consideration of other diagnoses or complications.