Gout

Gout

1. Definition

Gout is an inflammatory arthritis caused by deposition of monosodium urate crystals in joints and peri‑articular tissues. It usually begins with a sudden, excruciating pain in a single joint, most often the first metatarsophalangeal joint (big toe). The disease is chronic and may recur many times if the underlying hyperuricaemia is not controlled.

2. Synonyms (if any)

• Podagra – a term used when the gouty attack involves the big toe; it highlights the typical site of the first attack.

3. Causes / Etiology

4. Types / Classification

1. Acute gout – a single, rapid onset attack lasting from a few days up to two weeks.

   • Causes: sudden supersaturation of urate in synovial fluid, crystal precipitation.
   • Clinical features: intense throbbing pain, swelling, erythema, warmth; often nocturnal onset.
   • Duration: peaks within 24 h, subsides in 3–5 days, may linger up to 2 weeks.
   • Difference from chronic: isolated joint, no tophi, normal joint architecture.

2. Intercritical gout – symptom‑free interval between attacks.

   • Features: patient feels well, but serum urate remains high; risk of next attack persists.

3. Chronic gout – repeated attacks over months‑years with persistent hyperuricaemia.

   • Causes: inadequate urate‑lowering therapy, continued dietary excess, renal impairment.
   • Clinical features: polyarticular pain, joint deformities, tophi (subcutaneous urate deposits), chronic synovitis, possible joint erosion on X‑ray.
   • Duration: months to years; may become permanent disability if untreated.

5. Pathophysiology / Pathology

1. Hyperuricaemia – serum urate > 6.8 mg/dL exceeds its solubility limit.
2. Crystal formation – monosodium urate crystals precipitate in cooler peripheral joints.
3. Phagocytosis – neutrophils ingest crystals, become activated, and release inflammatory mediators (IL‑1β, TNF‑α).
4. Acute inflammation – intense vasodilation, increased vascular permeability, and influx of leukocytes produce the classic hot, red, painful joint.
5. Resolution – endogenous anti‑inflammatory mechanisms (IL‑1 receptor antagonist) gradually dampen the response.
6. Chronic deposition – repeated attacks lead to tophus formation, cartilage damage, and bone erosion.

6. Clinical Features

Acute gout

• Sudden onset, often at night.
• Excruciating pain localized to the joint, most commonly the first MTP.
• Swelling, erythema, and a shiny, stretched skin over the joint.
• The joint is exquisitely tender; even light touch (e.g., sheet) is painful.

Chronic gout

• Recurrent attacks involving multiple joints (ankles, knees, wrists).
• Persistent joint stiffness and reduced range of motion.
• Tophi: firm, chalky nodules in ears, olecranon, Achilles tendon, or fingers.
• Joint deformities and possible erosive changes visible on radiographs.

Relevance: Recognising the pattern of attacks and presence of tophi helps differentiate gout from other arthritides.

7. Complications

Acute complications

• Septic arthritis if secondary infection occurs.
• Acute uric acid nephrolithiasis causing renal colic.

Chronic complications

• Chronic kidney disease due to urate nephropathy.
• Cardiovascular disease: hyperuricaemia is an independent risk factor for hypertension and atherosclerosis.
• Joint destruction leading to permanent disability.

Importance: Early control of serum urate reduces risk of renal and cardiovascular sequelae.

8. Investigations / Diagnosis

• Serum uric acid – elevated level supports diagnosis but may be normal during an acute attack.
• Synovial fluid analysis – needle aspiration shows needle‑shaped, negatively birefringent crystals under polarized light; definitive.
• Complete blood count – leukocytosis may be present in acute inflammation.
• Renal function tests – assess kidney’s ability to excrete uric acid.
• Urinalysis – looks for uric acid crystals or stones.
• Imaging – plain X‑ray may show “punched‑out” erosions with overhanging edges; ultrasound can detect double‑contour sign of crystal deposition.

Purpose: Each test either confirms crystal presence, evaluates severity, or identifies organ involvement.

9. Differential Diagnosis

1. Pseudogout (Calcium pyrophosphate deposition disease) – calcium crystals are positively birefringent; often affects the knee and presents with milder redness.
2. Rheumatoid arthritis – symmetric polyarthritis, morning stiffness > 1 hour, rheumatoid factor positive; erosions are marginal rather than overhanging.
3. Septic arthritis – rapid joint swelling with fever, purulent synovial fluid, positive Gram stain; requires urgent antibiotics.
4. Acute osteoarthritis flare – limited to weight‑bearing joints, less intense pain, no crystal evidence.

Distinction: Crystal analysis and pattern of joint involvement are key discriminators.

10. Management / Treatment

General management

• Educate the patient about the chronic nature of gout and the need for lifelong urate control.
• Encourage weight reduction, regular exercise, and avoidance of alcohol and sugary drinks.

Modern medicine treatment

Acute attack

• NSAIDs (e.g., indomethacin) – rapid pain relief; monitor gastric and renal side effects.
• Colchicine – effective if started within 12 h; dose‑adjust for renal impairment.
• Systemic corticosteroids (prednisone) – used when NSAIDs/colchicine are contraindicated.

Chronic urate‑lowering therapy

• Allopurinol – xanthine oxidase inhibitor; start low, titrate to maintain serum urate < 6 mg/dL.
• Febuxostat – alternative when allopurinol intolerance occurs.
• Probenecid – increases renal uric acid excretion; useful in patients with good renal function.
• Pegloticase – intravenous enzyme for refractory cases.

Diet and lifestyle advice

• Limit purine‑rich foods (red meat, organ meat, anchovies, sardines).
• Reduce alcohol, especially beer and spirits.
• Increase water intake to at least 2–3 L/day to promote uric acid excretion.
• Maintain a healthy body weight; even modest loss lowers serum urate.

11. Homeopathic Therapeutics (7 remedies, each with 7–8 points)

1. Colchicum

• Causation – exposure to cold, damp weather or after over‑indulgence in rich foods.
• Characteristic symptoms – intense throbbing pain in the big toe, skin feels hot and stretched.
• Modalities – worse from cold, damp, and from lying on the affected side; better from warmth and gentle motion.
• Mental state – irritable, impatient, wants immediate relief.
• Thirst & appetite – great thirst for cold water; appetite reduced during attacks.
• Discharges/secretions – occasional watery discharge from the joint if effusion occurs.
• Physical generals – tendency to develop gout after heavy meals, especially in winter.
• Suitable constitution – robust individuals who over‑eat rich foods and are sensitive to cold.
• How it helps – removes the acute inflammatory surge and prevents recurrence by addressing the cold‑damp trigger.

2. Uricum

• Causation – hereditary tendency to high uric acid, often after prolonged intake of purine‑rich diet.
• Characteristic symptoms – sharp, stabbing pain in the metatarsophalangeal joint, swelling with a shiny appearance.
• Modalities – worse at night and after rest; better with gentle walking.
• Mental state – anxious about the next attack, seeks reassurance.
• Thirst & appetite – strong craving for cold drinks; appetite may be normal between attacks.
• Discharges/secretions – occasional milky synovial fluid on aspiration.
• Physical generals – family history of gout, frequent uric acid stones.
• Suitable constitution – individuals with a strong hereditary predisposition and a sedentary lifestyle.
• How it helps – lowers the uric acid burden and reduces crystal formation.

3. Ledum

• Causation – insect bite or sting on the foot, followed by swelling.
• Characteristic symptoms – burning pain that improves with cold applications, especially ice.
• Modalities – worse from warmth and pressure; better from cold compresses.
• Mental state – feels better when alone, dislikes being touched.
• Thirst & appetite – prefers cold water; appetite may be diminished during flare.
• Discharges/secretions – clear, thin joint fluid, no pus.
• Physical generals – history of skin eruptions or allergic reactions.
• Suitable constitution – people who are sensitive to insect bites and develop joint pain thereafter.
• How it helps – counteracts the cold‑induced inflammation and eases the burning sensation.

4. Apis mellifica

• Causation – sting of a bee or wasp, or exposure to hot, humid environments.
• Characteristic symptoms – swelling with a shiny, stretched skin, stinging pain that is relieved by cold.
• Modalities – worse from warmth, better from cold water or ice.
• Mental state – feels restless, wants to move but is limited by pain.
• Thirst & appetite – great thirst for cold water; appetite may be normal.
• Discharges/secretions – clear, watery effusion, sometimes with a faint sweet smell.
• Physical generals – tendency to develop hives or allergic skin eruptions.
• Suitable constitution – individuals who react strongly to insect stings or hot climates.
• How it helps – reduces the swelling and the stinging quality of the pain.

5. Bryonia alba

• Causation – over‑exertion of the foot, prolonged standing or walking on hard surfaces.
• Characteristic symptoms – severe, crushing pain that worsens with any movement; the joint feels “tight”.
• Modalities – worse from motion, pressure, and cold; better when the limb is completely at rest.
• Mental state – irritable, wants to be left alone, dislikes being disturbed.
• Thirst & appetite – thirst for large quantities of cold water; appetite may be reduced.
• Discharges/secretions – scanty, thick synovial fluid if aspirated.
• Physical generals – tendency to develop joint pain after physical strain.
• Suitable constitution – persons who are very active, then forced to rest abruptly.
• How it helps – alleviates the aggravation caused by movement and eases the crushing pain.

6. Rhus toxicodendron

• Causation – over‑exertion, especially after a cold, damp exposure; may follow a sprain.
• Characteristic symptoms – stiffness and aching that improve with gentle motion and warm applications.
• Modalities – worse from cold, damp, and initial movement; better from warmth and continued motion.
• Mental state – restless, eager to move once the initial stiffness eases.
• Thirst & appetite – prefers warm drinks; appetite may be normal.
• Discharges/secretions – occasional clear joint fluid, no pus.
• Physical generals – history of skin eruptions after contact with poison ivy or similar plants.
• Suitable constitution – individuals who feel better after the joint “warms up” with movement.
• How it helps – balances the cold‑damp aggravation and promotes gentle mobility.

7. Lycopodium clavatum

• Causation – pressure on the foot, over‑eating rich foods, and emotional stress.
• Characteristic symptoms – burning pain in the big toe that is worse on the right side, with a feeling of heaviness.
• Modalities – worse from warm drinks, cold air, and after meals; better from fresh air and rest.
• Mental state – anticipatory anxiety, fear of failure, often feels insecure.
• Thirst & appetite – great thirst for warm water; appetite for sweets and starchy foods.
• Discharges/secretions – scanty, sometimes sticky synovial fluid.
• Physical generals – tendency to develop digestive disturbances (bloating, flatulence).
• Suitable constitution – people who are ambitious, over‑work, and have a weak digestive system.
• How it helps – relieves the burning pain and addresses the underlying digestive and emotional factors that aggravate gout.

12. Prognosis

With appropriate urate‑lowering therapy, dietary control, and lifestyle modification, most patients achieve remission and can lead a normal life. Poor prognosis is associated with frequent attacks, large tophi, renal impairment, and uncontrolled hyperuricaemia, which increase the risk of joint destruction and cardiovascular disease.

13. Prevention

• Maintain a low‑purine diet and limit alcohol, especially beer.
• Keep well hydrated (≥ 2 L water daily) to facilitate uric acid excretion.
• Achieve and sustain a healthy body weight; even a 5 % weight loss lowers serum urate.
• Monitor serum urate regularly and adjust medication to keep levels below 6 mg/dL.

Importance: Preventive measures reduce the frequency of attacks, prevent tophus formation, and protect renal and cardiovascular health.

14. Diet