Gout: An old disease in new perspective - A review

Abstract

Gout is a picturesque presentation of uric acid disturbance. It is the most well understood and described type of arthritis. Its epidemiology is studied. New insights into the pathophysiology of hyperuricemia and gouty arthritis; acute and chronic allow for an even better understanding of the disease. The role of genetic predisposition is becoming more evident. The clinical picture of gout is divided into asymptomatic hyperuricemia, acute gouty arthritis, intercritical period, and chronic tophaceous gout. Diagnosis is based on laboratory and radiological features. The gold standard of diagnosis is identification of characteristic MSU crystals in the synovial fluid using polarized light microscopy. Imaging modalities include conventional radiography, ultrasonography, conventional CT, Dual-Energy CT, Magnetic Resonance Imaging, nuclear scintigraphy, and positron emission tomography. There is remarkable progress in the application of ultrasonography and Dual-Energy CT which is bound to influence the diagnosis, staging, follow-up, and clinical research in the field. Management of gout includes management of flares, chronic gout and prevention of flares, as well as management of comorbidities. Newer drugs in the pharmacological armamentarium are proving successful and supplement older ones. Other important points in its management include patient education, diet and life style changes, as well as cessation of hyperuricemic drugs.

Keywords: Clinical picture of gout; Gout; Hyperuricemia; Imaging modalities; Management of gout; Pathogenesis.

Graphical abstract

Fig. 1

Pathogenesis of hyperuriceamia (perceived and designed by Dr. EL-Shahaly).

Fig. 2

Renal excretion of uric acid (perceived and designed by Dr. EL-Shahaly).

Fig. 3

Pathogenesis of acute gouty inflammation (perceived and designed by Dr. EL-Shahaly).

Fig. 4

Chronic tophaceous gout: (a) hands, (b) ankle, (c) left greater toe (from the private collection of the authors).

Fig. 5

Three examples of Ultrasonography in gout. (a) Intraarticular tophus, metatarsophalangeal joint; (b) Double contour sign; (c) Longitudinal image of extensor digitorum longus (EDL) tendon showing markedly distended sheath with synovial effusion, synovial hypertrophy and crystal aggregates (arrows) (Courtesy of Dr. Adham Aboul-Fotouh, Kasr Alainy Teaching Hospital, Cairo University).

Fig. 6

DECT of a gouty patient showing two views of MSU deposits (in red) in the tibialis posterior tendon (from the private collection of prof. Bardin.

Fig. 7

EULAR recommendation for the management of flares in patients with gout .

Fig. 8

EULAR recommendation for the management of hyperuricemia in patients with gout .