eMedicine Specialties > Orthopedic Surgery > Systemic Diseases

Gout: Differential Diagnoses & Workup

Author: Bruce M Rothschild, MD, Professor of Medicine, Northeastern Ohio Universities College of Medicine; Adjunct Professor, Department of Biomedical Engineering, University of Akron; Adjunct Professor, Department of Anthropology, University of Kansas; Director, Arthritis Center of Northeast Ohio
Contributor Information and Disclosures

Updated: Jan 29, 2010

Differential Diagnoses

Arthritis as a Manifestation of Systemic Disease
Rheumatoid Arthritis
Bursitis
Rheumatoid Spondylitis
Chondrocalcinosis
Septic Arthritis
Forearm Fractures
Septic Arthritis, Pediatrics
Malignant Lymphoma
Monteggia Fracture
Myeloma

Other Problems to Be Considered

Type IIA hyperlipoproteinemia
Amyloidosis
Multicentric reticulohistiocytosis
Hyperparathyroidism
Spondyloarthropathy
Sarcoid
Avascular necrosis
Tumor
Infectious arthritides
Malignant soft tissue tumors
Milk-alkali syndrome
Pigmented villonodular synovitis
Pseudogout
Psoriatic arthritis
Reiter syndrome
Renal osteodystrophy
Rheumatoid arthritis

Workup

Laboratory Studies

  • Synovial fluid wet mount examination reveals negatively birefringent urate crystals on polarizing examination in 85% of specimens. Synovial fluid WBC count usually is 10,000-70,000/µL, but it may be as low as 1000/µL.
  • Peripheral WBC count often is elevated, with left shift during acute attacks.
  • Erythrocyte sedimentation rate usually is elevated during acute attacks.
  • Hyperuricemia is present in 95% of cases but is not diagnostic.
  • Once the acute gout episode is controlled, 24-hour urine uric acid levels also are assessed for choosing medication to control the associated hyperuricemia.

Imaging Studies

  • Routine radiographs reveal punched-out erosions or lytic areas with overhanging edges, as shown in the image below, but generally not within the first year of disease onset. Erosions with overhanging edges generally are considered pathognomonic for gout but also can be found in amyloidosis, multicentric reticulohistiocytosis, and type IIA hyperlipoproteinemia. Erosion with joint space preservation is typical.36,37 Plain radiographs and CT are complementary for recognizing erosions in gout.38

    • Gout. Radiograph of erosions with overhanging edg...

      Gout. Radiograph of erosions with overhanging edges.

      [ CLOSE WINDOW ]
      Gout. Radiograph of erosions with overhanging edg...

      Gout. Radiograph of erosions with overhanging edges.


  • In a study comparing identification of nephrolithiasis in gout patients by CT imaging versus a history of urinary tract calculus, 62% of the patients with CT-documented scans had no history of urolithiasis. In 383 male patients with primary gout, CT scanning confirmed nephrolithiasis in 103 (26.9%), whereas the history of urinary tract calculus was positive in only 65 (17%) patients. The authors concluded that an accurate prevalence of urolithiasis cannot be determined by patients' histories.39
  • MRI depicts gouty tophi, which have low or intermediate signal intensity on T1-weighted spin echo images. Signal intensity also tends to be low on T2-weighted images. In the absence of inflammation, the tophi are sharply delineated. Presence of inflammation results in increased perilesional signal intensity related to inflammation. Tophi and the surrounding area of inflammation enhance with gadolinium.40
  • Indium-111–labeled leukocyte scans, usually used to identify infectious foci, also reveal intense accumulation in affected joints in gout.41
  • Dual-energy CT, using a renal stone color-coding protocol, assesses chemical composition, labeling urate deposits in red.42

Procedures

  • Biopsy findings in synovial membrane or nodules include uric acid crystals if the biopsy is properly processed. As uric acid is water-soluble, the pathologic specimens need to be processed anhydrously.
  • Arthrocentesis of the affected joint provides fluid for analysis under polarizing microscopy.

Histologic Findings

Polarizing microscopy reveals negatively birefringent crystals.

More on Gout

Overview: Gout
Differential Diagnoses & Workup: Gout
Treatment & Medication: Gout
Follow-up: Gout
Multimedia: Gout
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Currie WJ. The gout patient in general practice. Rheumatol Rehabil. Nov 1978;17(4):205-17. [Medline].

  2. Martinon F, Glimcher LH. Gout: new insights into an old disease. J Clin Invest. Aug 2006;116(8):2073-5. [Medline].

  3. So A. Gout in the spotlight. Arthritis Res Ther. 2008;10(3):112. [Medline].

  4. Martinon F. Mechanisms of uric acid crystal-mediated autoinflammation. Wiley InterScience. Available at http://www3.interscience.wiley.com/journal/123226222/abstract?CRETRY=1&SRETRY=0. Accessed January 29, 2010.

  5. Bluestone R, Waisman J, Klinenberg JR. The gouty kidney. Semin Arthritis Rheum. Nov 1977;7(2):97-113. [Medline].

  6. Edwards NL. Treatment-failure gout: A moving target. Arthritis Rheum. Sep 2008;58(9):2587-90. [Medline].

  7. Appleby EC, Siller WG. Some cases of gout in reptiles. J Pathol Bacteriol. Oct 1960;80:427-30. [Medline].

  8. Schmidt RE, Hubbard GB. Atlas of Zoo Animal Patholology. II. Avian, Reptile and Miscellaneous Species. London: CRC Press;. 1987.

  9. Siller WG. Avian nephritis and visceral gout. Lab Invest. Nov-Dec 1959;8:1319-57. [Medline].

  10. Schlumberger HG. Synovial gout in the parakeet. Lab Invest. Nov-Dec 1959;8:1304-18. [Medline].

  11. Mendelson W. On guanin gout in the hog, and its relations to the sodium urate gout of man. Amer J Med Sci. 1888;95:109-22.

  12. Carvalho M, Lulich JP, Osborne CA, Nakagawa Y. Role of urinary inhibitors of crystallization in uric acid nephrolithiasis: Dalmatian dog model. Urology. Sep 2003;62(3):566-70. [Medline].

  13. Rothschild BM, Tanke D, Carpenter K. Tyrannosaurs suffered from gout. Nature. May 22 1997;387(6631):357. [Medline].

  14. Terkeltaub RA. Gout: Recent advances and emerging therapies. Rheumatic Disease Clinics Update. 2008;3(1):1-9.

  15. Miao Z, Li C, Chen Y, Zhao S, Wang Y, Wang Z, et al. Dietary and lifestyle changes associated with high prevalence of hyperuricemia and gout in the shandong coastal cities of eastern china. J Rheumatol. Sep 2008;35(9):1859-64. [Medline].

  16. Mould-Quevedo J, Peláez-Ballestas I, Vázquez-Mellado J, Terán-Estrada L, Esquivel-Valerio J, Ventura-Ríos L, et al. [Social costs of the most common inflammatory rheumatic diseases in Mexico from the patient's perspective]. Gac Med Mex. May-Jun 2008;144(3):225-31. [Medline].

  17. Reed D, Labarthe D, Stallones R. Epidemiologic studies of serum uric acid levels among Micronesians. Arthritis Rheum. Jul-Aug 1972;15(4):381-90. [Medline].

  18. Rose BS. Gout in Maoris. Semin Arthritis Rheum. Nov 1975;5(2):121-45. [Medline].

  19. Rothschild BM, Heathcote GM. Characterization of gout in a skeletal population sample: presumptive diagnosis in a Micronesian population. Am J Phys Anthropol. Dec 1995;98(4):519-25. [Medline].

  20. Yu T, Talbott JH. Changing trends of mortality in gout. Semin Arthritis Rheum. Aug 1980;10(1):1-9. [Medline].

  21. Forman JP, Choi H, Curhan GC. Uric acid and insulin sensitivity and risk of incident hypertension. Arch Intern Med. Jan 26 2009;169(2):155-62. [Medline].

  22. Kim SY, De Vera MA, Choi HK. Gout and mortality. Clin Exp Rheumatol. Sep-Oct 2008;26(5 Suppl 51):S115-9. [Medline].

  23. Hochberg MC, Thomas J, Thomas DJ, et al. Racial differences in the incidence of gout. The role of hypertension. Arthritis Rheum. May 1995;38(5):628-32. [Medline].

  24. Mody GM, Naidoo PD. Gout in South African blacks. Ann Rheum Dis. Jun 1984;43(3):394-7. [Medline].

  25. Choi KC, Curhan G. Soft drinks, fructose consumption, and the risk of gout in men: prospective cohort study. British Medical Journal. January/2008;336:10.1136/bmj.39449.819271.BE.

  26. Choi HK, De Vera MA, Krishnan E. Gout and the risk of type 2 diabetes among men with a high cardiovascular risk profile. Rheumatology (Oxford). Aug 18 2008;[Medline].

  27. Yarom A, Rennebohm RM, Strife F, Levinson JE. Juvenile gouty arthritis. Two cases associated with mild renal insufficiency. Am J Dis Child. Oct 1984;138(10):955-7. [Medline].

  28. Singh H, Torralba KD. Therapeutic challenges in the management of gout in the elderly. Geriatrics. Jul 2008;63(7):13-8, 20. [Medline].

  29. Olaniyi-Leyimu BY. Consider gout in patients with risk factors, regardless of age. Am Fam Physician. Jul 15 2008;78(2):176. [Medline].

  30. Resnick D, Niwayama G. Diagnosis of Bone and Joint Disorders. Philadelphia, Pa: Saunders;. 1988.

  31. Hadler NM, Franck WA, Bress NM, Robinson DR. Acute polyarticular gout. Am J Med. May 1974;56(5):715-9. [Medline].

  32. Lawry GV 2d, Fan PT, Bluestone R. Polyarticular versus monoarticular gout: a prospective, comparative analysis of clinical features. Medicine (Baltimore). Sep 1988;67(5):335-43. [Medline].

  33. Konatalapalli RM, Demarco PJ, Jelinek JS, Murphey M, Gibson M, Jennings B, et al. Gout in the axial skeleton. J Rheumatol. Mar 2009;36(3):609-13. [Medline].

  34. Hall AP, Barry PE, Dawber TR, McNamara PM. Epidemiology of gout and hyperuricemia. A long-term population study. Am J Med. Jan 1967;42(1):27-37. [Medline].

  35. Lin HY, Rocher LL, McQuillan MA, et al. Cyclosporine-induced hyperuricemia and gout. N Engl J Med. Aug 3 1989;321(5):287-92. [Medline].

  36. Barthelemy CR, Nakayama DA, Carrera GF, et al. Gouty arthritis: a prospective radiographic evaluation of sixty patients. Skeletal Radiol. 1984;11(1):1-8. [Medline].

  37. Dalbeth N, Clark B, Gregory K, Gamble G, Sheehan T, Doyle A, et al. Mechanisms of bone erosion in gout; a quantitative analysis using plain radiography and computed tomography. Ann Rheum Dis. Aug 15 2008;[Medline].

  38. Dalbeth N, Clark B, Gregory K, Gamble G, Sheehan T, Doyle A, et al. Mechanisms of bone erosion in gout: a quantitative analysis using plain radiography and computed tomography. Ann Rheum Dis. Aug 2009;68(8):1290-5. [Medline].

  39. Shimizu T, Hori H. The prevalence of nephrolithiasis in patients with primary gout: a cross-sectional study using helical computed tomography. J Rheumatol. Sep 2009;36(9):1958-62. [Medline].

  40. Oostveen JC, van de Laar MA. Magnetic resonance imaging in rheumatic disorders of the spine and sacroiliac joints. Semin Arthritis Rheum. Aug 2000;30(1):52-69. [Medline].

  41. Palestro CJ, Vega A, Kim CK, et al. Appearance of acute gouty arthritis on indium-111-labeled leukocyte scintigraphy. J Nucl Med. May 1990;31(5):682-4. [Medline].

  42. Al-Arfaj AM, Nicolaou S, Eftekhari A, Munk P, Shojani K, Reid G, et al. Utility of dual energy computed tomography (DECT) i8n tophaceous gout. Arthritis Rheum. 2008;58:S878.

  43. Riedel AA, Nelson M, Joseph-Ridge N, Wallace K, MacDonald P, Becker M. Compliance with allopurinol therapy among managed care enrollees with gout: a retrospective analysis of administrative claims. J Rheumatol. Aug 2004;31(8):1575-81. [Medline].

  44. Nuki G. Colchicine: its mechanism of action and efficacy in crystal-induced inflammation. Curr Rheumatol Rep. Jul 2008;10(3):218-27. [Medline].

  45. Reber P, Crevoisier X, Noesberger B. Unusual localisation of tophaceous gout. A report of four cases and review of the literature. Arch Orthop Trauma Surg. 1996;115(5):297-9. [Medline].

  46. Schapira D, Stahl S, Izhak OB, et al. Chronic tophaceous gouty arthritis mimicking rheumatoid arthritis. Semin Arthritis Rheum. Aug 1999;29(1):56-63. [Medline].

  47. Shogan CP, Folio CL. Tophaceous gout and rheumatoid arthritis awareness. J Am Osteopath Assoc. Jul 2008;108(7):352; author reply 352-3. [Medline].

  48. Roddy E. Hyperuricemia, gout, and lifestyle factors. J Rheumatol. Sep 2008;35(9):1689-91. [Medline].

  49. Wu EQ, Yu AP, Guerin A, et al. The costs of treatment failure gout: a claims-based analysis. ACR/ARHP Scientific Meeting 2009. Available at http://acr.confex.com/acr/2009/webprogram/Paper16451.html. Accessed January 28, 2010.

  50. Dalbeth N, Horne A, Gamble GD, Ames R, Mason B, McQueen FM, et al. The effect of calcium supplementation on serum urate: analysis of a randomized controlled trial. Rheumatology (Oxford). Feb 2009;48(2):195-7. [Medline].

  51. Song EF, Xiang Q, Ren KM, Hu JC, Wu F, Gong MF, et al. Clinical effect and action mechanism of Weicao Capsule in treating gout. Chin J Integr Med. Jun 2008;14(2):103-6. [Medline].

  52. Becker MA, Schumacher HR Jr, Wortmann RL, et al. A phase 3 study comparing the safety and efficacy of oral febuxostat and allopurinol in subjects with hyperuricemia and gout. Arthritis Rheum. 2004;50:4103-4.

  53. Fam AG. Should patients with interval gout be treated with urate lowering drugs?. J Rheumatol. Sep 1995;22(9):1621-3. [Medline].

  54. Groff GD, Franck WA, Raddatz DA. Systemic steroid therapy for acute gout: a clinical trial and review of the literature. Semin Arthritis Rheum. Jun 1990;19(6):329-36. [Medline].

  55. Siegel LB, Alloway JA, Nashel DJ. Comparison of adrenocorticotropic hormone and triamcinolone acetonide in the treatment of acute gouty arthritis. J Rheumatol. Jul 1994;21(7):1325-7. [Medline].

  56. Sundy JS, Becker MA, Baraf HS, Barkhuizen A, Moreland LW, Huang W, et al. Reduction of plasma urate levels following treatment with multiple doses of pegloticase (polyethylene glycol-conjugated uricase) in patients with treatment-failure gout: Results of a phase II randomized study. Arthritis Rheum. Sep 2008;58(9):2882-91. [Medline].

  57. Singh JA Md Mph, Hodges JM, Asch SM. Opportunities for improving medication use and monitoring in gout. Ann Rheum Dis. Aug 13 2008;[Medline].

  58. Chesney W, Larson G, Lai C, Miampamba M, Walker H, Miner J. MEK inhibitor RDEA119 suppresses inflammatory cytokine production induced by monosodium urate crystals. Arthritis Rheum. 2008;58:S879.

  59. Schumacher HR Jr, Becker MA, Lloyd E, MacDonald PA, Lademacher C. Febuxostat in the treatment of gout: 5-yr findings of the FOCUS efficacy and safety study. Rheumatology (Oxford). Feb 2009;48(2):188-94. [Medline].

  60. Julkunen H, Heinonen OP, Pyorala K. Hyperostosis of the spine in an adult population. Its relation to hyperglycaemia and obesity. Ann Rheum Dis. Nov 1971;30(6):605-12. [Medline].

  61. Koskoff YD, Morris LE, Lubic LG. Paraplegia as a complication of gout. JAMA. 1953;152:37-8.

  62. Nguyen C, H-K E, Palazzo E, Liote F. Tophaceous gout: an unusual cause of multiple fractures. Informaworld. Available at http://www.informaworld.com/smpp/content~content=a915825452~db=all~jumptype=rss. Accessed January 28, 2010.

  63. Schumacher HR, Taylor W, Joseph-Ridge N, Perez-Ruiz F, Chen LX, Schlesinger N. Outcome evaluations in gout. J Rheumatol. Jun 2007;34(6):1381-5. [Medline].

  64. Becker MA, MacDonald PA, Hunt BJ, Lademacher C, Joseph-Ridge N. Determinants of the clinical outcomes of gout during the first year of urate-lowering therapy. Nucleosides Nucleotides Nucleic Acids. Jun 2008;27(6):585-91. [Medline].

[ CLOSE WINDOW ]

Keywords

gout, hyperuricemiaurate, crystal arthropathy, podagra, urate deposition disease, inflammatory arthritis, chronic arthritis, bursitis, rheumatoid arthritis

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Bruce M Rothschild, MD, Professor of Medicine, Northeastern Ohio Universities College of Medicine; Adjunct Professor, Department of Biomedical Engineering, University of Akron; Adjunct Professor, Department of Anthropology, University of Kansas; Director, Arthritis Center of Northeast Ohio
Bruce M Rothschild, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Rheumatology, International Skeletal Society, New York Academy of Sciences, Sigma Xi, and Society of Skeletal Radiology
Disclosure: Nothing to disclose.

Medical Editor

Jegan Krishnan, MBBS, FRACS, PhD, Professor, Chair, Department of Orthopedic Surgery, Flinders University of South Australia; Senior Clinical Director of Orthopedic Surgery, Repatriation General Hospital; Private Practice, Orthopaedics SA, Ashford Specialist Centre
Jegan Krishnan, MBBS, FRACS, PhD is a member of the following medical societies: Australian Medical Association, Australian Orthopaedic Association, and Royal Australasian College of Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Paul E Di Cesare, MD, FACS, Chair and Professor, Department of Orthopedic Surgery, University of California Davis School of Medicine
Paul E Di Cesare, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, and Sigma Xi
Disclosure: stryker Consulting fee Consulting

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.