George M. Bridgeforth and Kris Alden

A 57-year-old postmenopausal woman presents with acute bilateral hand pain, swelling, and erythema. she has had intermittent attacks characterized by redness swelling of the great toe, the knee, and the ankle for several days.

CLINICAL POINTS

Gout is more common in men.
Periodic attacks and remissions characterize gout. Au2 noted and appreciated.
The most commonly affected joints are in the feet or hands, as well as the knee, ankle, elbow, or wrist.

Clinical Presentation

Gout is a condition that affects approximately 2% of the population. In younger age groups, it affects men more than women 9:1. However, the ratio declines with advancing age with a male to female ratio of 3:1 following menopause. Moreover, the age distribution is different as well. It commonly begins in males between 30 and 45 years of age and in postmenopausal females. The incidence of gout continues to increase with advancing age.

Gout usually presents as an oligoarthritis; it is caused by the deposition of monosodium urate crystals in the joint space. The disease is manifested by either an overproduction or an underexcretion of uric acid.

Gout is characterized by a history of acute attacks and remissions. Acute attacks usually last for several (5–10) days and are characterized by marked redness, warmth, swelling, and tenderness. Sixty percent of patients with gout have a second attack within 1 year, and 78% have a second attack within 2 years. The most commonly affected joint is the great toe. However, other joints such as the knees, ankles, fingers, and elbows may be affected. Most flare-ups affect a single joint. However, severe cases may affect multiple joints. Widespread, disabling joint destruction is uncommon, except in severe cases.

Tophi, which are permanent collections of uric acid crystals, may be seen in severe cases. They may be seen on the metacarpal heads (i.e., the knuckles), lower ear lobes, olecranon (tips of the elbows), and the Achilles tendons. In addition, tophi may appear over the distal interphalangeal or proximal interphalangeal joints in patients with concomitant osteoarthritis. Generally, it takes more than 10 years to develop gouty tophi. However, tophi have a higher risk of developing in untreated or poorly treated patients. Kidney stones occur in approximately 15% of patients with gout.

Radiographic Evaluation

Usually standard radiographs are sufficient. CT or MRI scans are usually not required. Necessary tests depend on the area of involvement. It is not uncommon for patients with nontraumatic medical conditions to relate them to injuries.

PATIENT ASSESSMENT

Marked redness, warmth, and swelling of virtually any joint
Usually oligoarticular and asymmetric arthritis characterized by flare-ups followed by periods of remission
Severe pain; complaint of painful weight bearing when pain affects the lower extremities

FIGURE 53.1 AP radiographs of the (A) left and (B) right hands from the patient in the opening case demonstrating periarticular soft tissue swelling (arrowheads), marginal erosions (arrows), and preservation of the joint space and bone mineralization compatible with gouty arthritis.

Gout can often manifest as periarticular erosions with predominant soft tissue swelling involving the affected joint. One of the pathognomonic features of gout are the hourglass-shaped periarticular erosions with a characteristic appearance, resembling bites out an apple with sharp rounded edges (Fig. 53.1). Greenspan describes these erosions as having a characteristic “overhanging edge” (Fig. 53.2). If the examiner looks closely (especially if the patient has had a history of a prior attack affecting the particular joint), there may be radiographic evidence of early periarticular involvement. The periarticular bone may appear less dense in that region.

FIGURE 53.2 Oblique radiograph of the left hand in a patient with gout demonstrating the typical “rat bite” erosions (arrow) of the third proximal interphalangeal joint and overhanging edge (arrowhead).

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