Painful Great Toe

An 84 year old woman presents with pain, redness, and swelling of the left great toe, which makes it difficult for her to walk. She is concerned about possible gout.

What you should cover

Acute gout usually presents as painful inflammation of a single joint. Podagra (inflammation of the first metatarsophalangeal joint) is the most common presentation. Less common presentations include tenosynovitis, bursitis, entrapment neuropathies, and axial gout with back, neck, or radicular pain.1

Gouty arthritis is caused by deposits of uric acid crystals in joints. Acute attacks may be triggered by local changes in body temperature or pH; trauma; or articular dehydration. Gout can progress through four clinical stages: asymptomatic hyperuricaemia, acute gout with painful arthropathy, interval gout, and chronic tophaceous gout. The presence of hyperuricaemia alone does not necessarily mean that the patient has gout.2

The most important differential diagnosis besides gout to consider for an acutely inflamed joint is septic arthritis, usually associated with joint effusion and positive Gram stain on joint aspirate. Other diagnoses to consider include calcium pyrophosphate dihydrate deposition disease (typically self limited, affecting the knee, and associated with normal uric acid concentrations); rheumatoid, psoriatic, or reactive arthritis; cellulitis, Reiter’s syndrome, and sarcoidosis.3

Although definitive diagnosis of gout requires presence of uric acid crystals in joint fluid, a clinical diagnosis of crystal arthropathy is reasonable in patients with rapid development of severe pain, swelling, tenderness, and overlying erythema that peaks within six to 12 hours. If monoarticular inflammation and hyperuricaemia are or have been recurrent, a clinical diagnosis of gout is reasonable.2 The box outlines criteria for the diagnosis of gout on the basis of clinical findings.

Criteria for diagnosis of gout on the basis of clinical findings

European League Against Rheumatism (EULAR)4

• In acute attacks the rapid development of severe pain, swelling, and tenderness that reaches its maximum within just 6-12 hours, especially with overlying erythema, is highly suggestive of crystal inflammation though not specific for gout
• For typical presentations of gout (such as recurrent podagra with hyperuricaemia) a clinical diagnosis alone is reasonably accurate but not definitive without crystal confirmation

Janssens clinical prediction rule (www.umcn.nl/goutcalc)5

• Gout is highly unlikely with a total score of ≤4 and is >80% likely with a total score of ≥8:
  • -Male sex—2.0 points
  • -Previous arthritis attack reported by the patient—2.0 points
  • -Onset in <1 day—0.5 point
  • -Joint redness—1.0 point
  • -Involvement of first metatarsophalangeal joint—2.5 points
  • -Hypertension or one or more cardiovascular diseases—1.5 points
  • -Serum uric acid concentration >350 μmol/l—3.5 points
    
    

    What you should do

    • For a patient with acute podagra ask about onset, course, and severity of pain; presence of other affected joints; fever; precipitating or exacerbating factors; and whether this is a new or recurrent problem.
    • Assess for risk factors for gout: older age, male sex, high alcohol use, cardiovascular disease, hypertension, diabetes, thyroid dysfunction, obesity, chronic kidney disease, diuretic treatment, and a current or previous raised serum uric acid concentration. If available, obtain laboratory studies for serum uric acid concentration, blood counts, renal function, and thyroid function.
    • If a patient scores ≥8 on the Janssens prediction rule (box) or has podagra and a documented history of gout, it is appropriate to treat empirically without waiting for laboratory results.
    • Initial treatment should focus on terminating the acute attack with non-steroidal anti-inflammatory drugs, colchicine, or corticosteroids. Non-steroidal anti-inflammatory drugs, which work faster but can carry risks of gastrointestinal or renal toxicity, should be given at recommended maximum doses. Colchicine, which may be slower to work and carries risks of gastrointestinal upset and diarrhoea, should be given at an initial dose of 1.2 mg, followed by 0.6 mg one hour later, then 0.6 mg three times daily until the attack settles. Oral corticosteroids (such as prednisone 20-40 mg daily for three days then tapered over two weeks) are an option in patients intolerant of non-steroidal anti-inflammatory drugs and colchicine.2
    • Important ancillary interventions include rest, raising the leg, ice packs for the affected joint, hydration (up to two litres of water a day), and reducing alcohol intake. Stopping or replacing diuretic medications may be helpful.
    • Arrange for aspiration of the joint for Gram stain and culture and for assessment for uric acid or calcium pyrophosphate crystals in any of the following cases:
      • -A patient scores ≤4 on the Janssens prediction rule
      • -A joint other than the first metatarsophalangeal is involved
      • -Uric acid concentrations are normal
      • -Other factors raise suspicion of septic arthritis.
    • Lifestyle interventions that may help reduce the risk of recurrent gout include weight loss, eating one less portion of meat or fish a day, drinking wine instead of beer, and drinking one glass of skimmed milk daily.6 7
      
      BMJ 2010; 341 doi: 10.1136/bmj.c6155 (Published 15 November 2010)
      Cite this as: BMJ 2010;341:c6155
      
      

      William E Cayley Jr, associate professor

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