Acute gouty arthritis is an inflammation of the joint due to the accumulation of sodium monaurate crystals in the periarticular tissues and their subsequent release under the influence of provoking factors. Most often affects the I metatarsophalangeal joint. It is characterized by sharp pains, local edema and hyperemia, fever, general hyperthermia. After a few days, the symptoms disappear, but later there are new attacks with the transition of gout into a chronic form. It is diagnosed on the basis of complaints, anamnesis, physical examination data, laboratory and hardware techniques. Treatment includes NSAIDs, means for correcting uric acid metabolism, glucocorticosteroids.
ICD 10
M10 Gout
Meaning
Acute gouty arthritis is the most common type of arthritis in men over 40 years of age. It is the second stage of gout, develops after asymptomatic hyperuricemia. The peak incidence in the stronger sex is 40-50 years old, in women – 60 years or more. Pathology is rarely detected in men under 30 years of age and women who have not reached the age of menopause. Among patients under 50 years of age, there is a 6-7-fold predominance of men, and subsequently the difference in sexual distribution gradually decreases.
Causes
Gouty arthritis is always formed against the background of previous persistent hyperuricemia. The uric acid level of more than 420 mmol/l is considered critical. In women, crystals can be deposited already at 360 mmol/l. The risk factor is not only an increase in the amount of uric acid, but also its sharp fluctuations. The increase in the content of urates is promoted by:
- Irrational nutrition. Fish, red meat, and foods with a large amount of fructose are considered “dangerous”.
- Excess weight. Gout often develops in obese people. It often occurs after a sharp increase in body weight.
- Alcohol abuse. Along with obesity, it is one of the two most significant provoking factors. The use of both strong alcoholic beverages and beer is important.
- Taking medications. Hyperuricemia occurs more often when taking diuretics, ethambutol, pyrazinamide, nicotinate, cyclosporine, beta-blockers, low-dose aspirin.
- Strengthening the exchange of purines. It is observed in hemoglobinopathies, chronic hemolytic anemia, thalassemia, secondary polycythemia, lympho- and myeloproliferative diseases, psoriasis.
- Increase in the production of purines. It is detected in Lesh-Nihan syndrome, lack of glucose-6-phosphate dehydrogenase.
Risk factors
Factors provoking an attack of acute arthritis on the background of hyperuricemia are traumatic injuries, dehydration, blood loss, alcohol consumption, food with a high content of purines (meat, sardines, shellfish). Gouty attack develops against the background of acute infectious diseases, taking medications (nicotinic acid, aspirin, vitamin B12, allopurinol, diuretics), radiation therapy. Sometimes the reason is high physical activity. Symptoms may also appear on 3-5 days after various operations.
Pathogenesis
Due to the high content of urates in the blood, they accumulate in the body and are deposited in tissues, forming needle-like crystals that are normally covered with lipoproteins. First of all, the pathological process covers the distal parts of the lower extremities, which is explained by a decrease in the solubility of uric acid due to a lower temperature in remote areas of the body. When crystals are deposited from the synovial fluid or their release from lipoproteins, certain immune reactions are triggered.
Against the background of crystal phagocytosis, the amount of intracellular sodium in cells increases, which stimulates the transfer of fluid into cells with their swelling. Simultaneous decrease in potassium level stimulates the activity of intracellular structures, which results in enhanced synthesis of cytokines, tumor necrosis factor, interleukins. Local vessels expand, neutrophils actively migrate to the site of the lesion. An acute gouty attack develops.
Classification
Gout can be primary or secondary (symptomatic). The primary form is based on the increased production of uric acid or its insufficient excretion through the kidneys. The symptomatic variant develops when taking medications, kidney pathologies, hereditary enzyme defects, myeloproliferative diseases.
The severity of a gouty attack is determined by the severity of the pain syndrome. When assessing pain less than 4 on a ten–point scale, acute gouty arthritis is considered mild, at 5-6 – moderate, at 7 or more – severe. The effectiveness of arresting an attack directly depends on the time of the patient’s request for medical help. If less than 12 hours have passed after the onset of symptoms, arthritis is considered early, from 12 to 36 hours – diagnosed in a timely manner, more than 36 hours – late.
The prevalence of the acute process is estimated by the number of joints involved:
- one or more small;
- 1-2 medium or large;
- 3 and larger, or 4 and more medium and large, or a regional lesion (polyarticular gout).
Symptoms
At the first attacks of gout, the distal joints of the legs are affected in the absolute majority of patients. The first place in prevalence is occupied by 1 metatarsophalangeal joint (more than half of the total number of cases), it is possible to involve other parts of the foot, knee, ankle, elbow, wrist joint, hand joints. The defeat of large joints never develops in the debut, can be observed with subsequent exacerbations.
The localization of arthritis is largely determined by the age and gender of the patient. Men are more likely to suffer from inflammation of the thumb. Women at an early stage of gout, as a rule, have poly- or oligoarthritis involving the distal parts of the hands. In elderly patients, polyarticular lesion of the upper extremities with rapid formation of tofuses is mainly detected.
Acute arthritis often manifests at night or early in the morning. Pain suddenly appears in the affected joint. Painful sensations quickly increase, become extremely intense, reach a maximum in a few hours. There is a “symptom of the sheet” – a sharp soreness from the usual touch of the foot to the fabric. The joint swells, the skin above it turns red, acquires a shiny “glossy” appearance.
The function is significantly disrupted, support becomes impossible. There is an increase in body temperature, fever, weakness, chills. Some patients develop tenosynovitis and bursitis. Even without treatment, the symptoms disappear completely after a few days. Sometimes acute gouty arthritis proceeds relatively easily, manifestations are independently stopped before the specified period. The intervals between seizures vary from a few days to several years. In 62% of patients, a repeated attack develops within 1 year.
The time of formation of tofuses varies greatly. In most cases, they appear several years after the onset of gout, when arthritis becomes chronic. But sometimes these formations are detected within a couple of months after the manifestation of the disease, so their presence should be checked even at the first gouty attacks.
Diagnostics
The examination is carried out by a rheumatologist. During the survey, the specialist finds out complaints, the history of the disease. An important role is played by the identification of risk factors: metabolic syndrome (obesity, increased blood pressure, characteristic metabolic disorders), taking certain medications. The presence of renal pathologies, alcohol abuse, propensity to use certain foods is important.
In favor of the gouty nature of arthritis, rapid progression of symptoms, intense pain, erythema, typical localization, the presence of similar seizures in the anamnesis indicate. As part of a physical examination, the appearance and function of the joint are evaluated, the possible locations of the topuses are examined: elbows, first toes, auricles. Additional examination includes:
- Determination of uric acid. The indicator is detected in the blood serum. The presence of hyperuricemia is not a basis for diagnosis, but indicates an increased likelihood of developing gout. When evaluating the results, it is taken into account that during the attack the uric acid content may be normal, further studies in dynamics are recommended.
- Determination of urates. It is the “gold standard” for the diagnosis of gout. Synovial fluid obtained during joint puncture, or the contents of the topus taken by biopsy, are examined using polarization microscopy. The technique has almost 100% specificity, crystals are detected in 70% of cases.
- Other laboratory tests. In the blood test, an increase in ESR, leukocytosis, neutrophilosis is detected. A biochemical blood test confirms an increase in C-reactive protein. It is mandatory to determine ALT, AST, creatinine, and lipid profile. In patients with kidney damage, creatinine clearance is reduced. Changes in urine test depend on the nature of renal pathology.
- Ultrasound of the joint. The method is informative not only in the development of acute arthritis, but also before the onset of the first gouty attack (at the asymptomatic stage). It is especially important when it is impossible to study the synovial fluid. During sonography, the “double contour” of the joint, the picture of a “blizzard” in synovia are visualized. Sometimes topuses are viewed, having the appearance of heterogeneous hyperechoic lesions with anechoic edges.
- Radiography of the joint. At the stage of acute arthritis, it is not informative to confirm the diagnosis, changes in the pictures appear only 7-10 years after the manifestation of gout. Radiographs are used to exclude traumatic injuries and other joint diseases.
Differential diagnosis
The signs of a gouty attack are quite specific, but a similar pattern can be observed in some other pathologies, in particular, bursitis, soft tissue infections. The condition should be differentiated with pyrophosphate, septic, reactive arthritis. In some cases, a distinction with psoriatic, post-traumatic, rheumatoid arthritis is required. Sometimes it is necessary to exclude the peripheral form of spondyloarthritis, erysipelas, osteoarthritis.
Treatment
The basis of therapy is made up of medications of systemic and local action. Medicines of the following groups are used:
- Nonsteroidal anti-inflammatory drugs. Reduce pain syndrome, reduce the severity of inflammation. The preferred option is the maximum therapeutic doses of drugs with a short half-life.
- Affecting the metabolism of uric acid. Optimal assignment from the first hour of the attack. The later the treatment begins, the less pronounced the effect. Initially, a loading dose is administered, then they switch to half dosages every 6, 8 or 12 hours. Treatment is continued until the symptoms are relieved. For kidney diseases, they are used with caution.
- Glucocorticosteroids. They are used orally, since parenteral administration can cause “ricochet” syndrome. With oligo- and monoarthritis, they are injected into the joint or periarticular tissues on the first day of the disease.
- Genetically engineered biological preparations. Interleukin-1 antagonists are indicated in the absence of effect from other methods. They are not recommended in case of suspected septic arthritis, the presence of concomitant infectious diseases.
If the patient is already taking a xanthine oxidase inhibitor, the dose is reduced by 30-50%. Complete cancellation is undesirable, since the resumption of treatment may cause a new attack. If the drug has not been used before, it is not included in the therapy regimen, since it provokes a heavier course and an increase in the duration of the attack. Physiotherapy procedures in acute condition are contraindicated, because they do not provide the desired result, they can cause deterioration.
Forecast
The attack ends in 7-10 days. Since acute gouty arthritis is a manifestation of an already existing disease – gout, a complete cure is impossible, but with adequate therapy, compliance with medical recommendations, the prognosis is favorable. Unfavorable prognostic factors are considered to be young age, the presence of progressive kidney diseases, severe concomitant pathologies.
Prevention
The likelihood of new gouty attacks decreases with the observance of a special diet, abstinence from alcohol, normalization of body weight, treatment of provoking and concomitant diseases. If there are indications, hypouricemic and uricosuric drugs are prescribed to patients.