Primary Pathogenic Factor in Acute Gout
The major cause of this patient's acute gout attack is increased production of uric acid, driven by his purine-rich diet (red meat), which leads to hyperuricemia and subsequent monosodium urate crystal deposition in the joint. 1
Understanding the Pathophysiology
Gout develops through a clear mechanistic pathway that begins with hyperuricemia:
Hyperuricemia (serum uric acid >6.8 mg/dL) is the fundamental prerequisite for gout, as it leads to monosodium urate (MSU) crystal formation and accumulation in joints, cartilage, tendons, and soft tissues 2
MSU crystal deposition triggers the acute inflammatory response that manifests as the severe joint pain, swelling, and redness this patient is experiencing 1
The definitive diagnosis requires demonstration of MSU crystals in synovial fluid or tophus aspirates, which show needle-like appearance with strong negative birefringence under polarized microscopy 1
Role of Diet in Uric Acid Production
This patient's red meat-rich diet is a well-established contributor to his condition:
Purine-rich meat consumption increases gout risk with an adjusted relative risk of 1.41 (95% CI: 1.07-1.86), independent of other major risk factors like age, BMI, diuretic use, hypertension, and renal failure 1
Dietary purines from meat and seafood are metabolized to uric acid, leading to increased production and elevated serum uric acid levels 1
The American College of Rheumatology specifically recommends limiting purine-rich meat and seafood consumption in all gout patients to reduce both hyperuricemia and flare frequency 1
Why the Other Options Are Incorrect
Overhydration is not a cause of gout—in fact, dehydration is a known precipitant of gout flares 3
Increased excretion of uric acid would actually protect against gout, not cause it. The problem in most gout patients is either overproduction of uric acid (as in this patient with high purine intake) or underexcretion (often related to renal impairment or medications like diuretics) 1
Low purine diet would be protective, not causative—this is the opposite of what this patient has 1
Clinical Context and Risk Factors
This 50-year-old male fits the classic demographic profile:
Male sex carries an adjusted relative risk of 7.64 (95% CI: 7.46-7.81) for gout 1
The peak incidence of gout occurs in patients 30-50 years old, and the condition is much more common in men than women 4
The first metatarsophalangeal joint (big toe) is affected in 50% of initial gout attacks, making this presentation classic for acute gouty arthritis 5, 3
Important Clinical Pitfall
Serum uric acid levels may actually decrease during an acute attack, so a normal or low serum uric acid during the acute presentation does not exclude gout 3. The diagnosis should be confirmed by joint aspiration demonstrating MSU crystals when feasible 1.