DefinitionElbow Gout


Heterogeneous group of diseases characterised by

- hyperuricaemia

- recurrent attacks of acute arthritis


Diagnosis confirmed by

- crystals of Monosodium Urate in synovial fluid

- tophi ("Porous stone") urate in soft tissues

- renal urate stones




Adult men

- M:F = 20:1

- peak 40-60 years


Part of metabolic syndrome

- obese / HTN / high cholesterol / diabetes


Often have positive FHx




Prerequisite is hyperuricaemia at some stage

- determined by balance between production & excretion



- breakdown of nucleic acids

- oxidation of Purine bases (Guanine & Adenine)

- converted Inosine > Hypoxanthine > Xanthine > Uric Acid



- 2/3 excreted into urine

- 1/3 into GIT

- uric acid filtered at glomerulus

- reabsorbed in PCT 

- secreted in subsequent PCT




A.  Overproducers ~ 10%




Disturbance of Purine biosynthesis secondary to heritable error of metabolism

- usually idiopathic

- some specific enzyme known eg Lesch-Nyhan syndrome


Lesch-Nyhan Syndrome

- rare 

- X-linked recessive

- absence of enzyme in purine pathway HGPRT

- leads to excessive uric acid formation & gout

- young boys with mental retardation and self-mutilation




Diet high in purines

- alcohol / meat / seafood

Myeloproliferative disease

- leukaemia

Chronic hemolysis


Drugs eg salicylates, thiazide diuretics

Starvation, ketoacidosis



B.  Under-excretors ~ 90%


Secondary abnormal renal excretion of Uric acid

- diuretics





Acute Gouty Arthritis


Sustained hyperuricaemia 


Develop monosodium urate deposits

- in synovial lining cells & in cartilage on PG which are inert

- subsequently released into synovial fluid & CT 

- precipitates at > 8 mg/dl (trauma, low pH)


Sufficient number of crystals in joint precipitates acute inflammation

- phagocytosis of crystals

- release of chemotactic factors & inflammatory mediators

- activate complement & platelets

- disrupt lysosomes in leucocytes with cell rupture 


Chronic Gouty Arthritis


Tophi of Monosodium Urate Monohydrate Crystal aggregates

- deposited in synovium, cartilage & tendon sheaths

- lead to cartilage destruction & periarticular cyst formation


4 stages


1. Initial asymptomatic hyperuricaemia


2. First attack of acute gouty arthritis


3. When this settles, hyperuricaemia persists

- recurrent attacks

- frequency of attacks varies, may increase


4. Chronic gout

- joints no longer recovering from acute attacks

- arthritis & tophi develop





- in men begins at puberty

- in women starts at menopause


Risk of gout increases with

- serum urate level

- duration of hyperuricaemia

- usually develops after 20-30 years


Only 5% of hyperuricaemic patients develop gout


Takes days / weeks to resolve

- pain-free intervals of variable length


Clinical presentation


Acute Gouty Arthritis


Predominantly affects distal lower limb

- 70% initially attack 1st MTPJ (Podagra)


May also involve

- Other joints in foot

- ankle

- knee

- hands


Usually monoarticular, rapid onset 

- excruciating night pain

- hot red shiny swollen joint

- very painful to touch

- may have systemic features

- fever / leucocytosis / raised ESR


Onset may be spontaneous


May be precipitated by

- trauma

- excessive activity

- diet excess

- alcohol consumption

- diuretics

- systemic illness

- surgery


Chronic Gouty Arthritis



- after repeated attacks of gout

- asymmetric destructive arthropathy

- often involves small joints in hand



- 20% of cases

- white mass of sodium urate crystals

- visible underlying thinned-out skin

- may necrose overlying skin



- periarticular subcutaneous tissue

- helix of ear

- tendon sheaths especially Achilles

- olecranon / prepatellar bursae


Renal Stones

- 15% of cases

- radiotranslucent uric acid stones




Serum Uric Acid


Attacks of gout occur when levels of serum uric acid change

- not necessary to have increased serum urate during acute attack

- elevated serum urate in patient with painful joint not diagnostic of gout


Synovial fluid


Specimen must be anticoagulated

- must be very careful with sample as any water or alcohol put into it will dissolve the crystals


Monosodium urate crystals 

- diagnostic if found in synovial fluid 

- needle-shaped crystals 10um long

- lying free or in neutrophils 



- negatively birefringent under polarised light & parallel to 1st order red compensator

- bright yellow when parallel to compensator


Synovial fluid analysis 

- WCC of 1000 to 70 000 x 10.6/ L 

- predominantly neutrophils (< 70%)



- presence of crystals doesn't exclude infection

- infection precipitates urate


24 hr Urinary Uric Acid Secretion


> 1100mg /day 

- 50% chance renal stones

- treat with Allopurinol




Chronic Gouty Arthritis

- usually in feet in phalangeal heads 

- characteristic periarticular bony defects 

- punched out lytic appearance 

- overhanging sclerotic margin (Martell's sign)

- also joint space narrowing & secondary OA 

- no osteopenia compared with RA


Wrist Gout Severe





Septic arthritis

Acute bursitis




Seronegative spondyloarthropathy




Acute Gout






Action is as anti-inflammatory

- inhibits activation of inflammatory mediators by crystals

- very effective

- rapid response strongly suggestive of diagnosis

- 1 mg then 0.5 mg q2h up to maximum 6 mg / day

- continue till patient improves / diarrhea occurs / maximum dose

- 80% of patients unable to tolerate optimum dose because of GIT side-effects




Usually better tolerated than colchicine

- indomethacin most commonly used

- 50 mg t.d.s

- side effects include GIT toxicity / Sodium retention / CNS disturbance




Adrenocorticotrophic Hormone

- good for acute attack

- minimal side effects

- single 40 IU IM injection




Oral Prednisone

- if colchicine not tolerated / NSAID contraindicated


Intra-articular steroids

- may be used for severe monoarticular attack

- especially knee




3 Tier Approach




Lose weight

Increase fluids intack

Aim to decrease Purine intake and avoid precipitating factors

- alcohol

- diuretics

- diet - meat, seafood


2nd Stage

- Probenecid


3rd Stage

- Allopurinol

- beware hypersensitivity / bone marrow suppression




Absolute indications

- CRF secondary to kidney stones 


Relative indications

- > 3 acute attacks / year

- polyarticular gout

- tophi

- uric acid > 500 mmol/l




1. Increase Renal Uric Acid Excretion / Uricosuric

- Probenecid

- require good renal function


2. Decrease Uric Acid Synthesis

- Allopurinol




Inhibits Xanthine Oxidase

- 300 mg/day (150 if CRF) 

- hypersensitivity side effects in 20% 


Causes decrease in serum uric acid & this may precipitate acute attack of gout

- initiation of treatment should be accompanied by Colchicine or NSAIDS

- never used in acute gouty attack

- can shrink tophi if keep serum urate < 0.4mmol/l


Side effects can be fatal

- rash

- alopecia

- marrow suppression

- hepatitis