Can Gout Present Unilaterally?
Yes, gout characteristically begins as a unilateral, monoarticular arthritis, most commonly affecting a single joint—particularly the first metatarsophalangeal joint (podagra)—and this monoarticular pattern is the typical initial presentation in approximately 50% of cases. 1, 2
Initial Presentation Pattern
- Gout classically presents as monoarticular involvement affecting a single joint, with the first metatarsophalangeal joint being the initial site in half of all cases 2
- Monoarticular involvement of a foot or ankle joint is one of the most discriminating clinical features supporting a diagnosis of gout, with high predictive value 1
- The European League Against Rheumatism identifies monoarticular arthritis as a key diagnostic feature, particularly when combined with rapid onset of severe pain and erythema 1
Disease Evolution
- While gout begins unilaterally in most patients, the disease can evolve from monoarticular to asymmetrical polyarticular involvement as monosodium urate crystals accumulate over time 3
- Longer disease duration and chronic hyperuricemia increase the risk of polyarticular involvement, with multiple joints becoming affected simultaneously in more advanced disease 3
- The American College of Rheumatology recognizes that polyarticular gout (defined as 3 or more large joints or 4+ joints across multiple regions) represents a more severe disease pattern that typically develops later 1, 3
Clinical Implications for Diagnosis
- The presence of unilateral joint involvement does not exclude gout—in fact, it is the expected presentation, especially in early disease 1, 2
- When evaluating suspected gout, clinicians should look for: rapid onset reaching maximum pain within 6-24 hours, erythema over the joint, male gender, previous similar attacks, and hyperuricemia 1, 4
- Synovial fluid analysis remains the gold standard for definitive diagnosis, with monosodium urate crystal identification providing near 100% sensitivity and specificity 1, 4