What are the symptoms of gout?
Gout is more common in middle-aged men, accounting for only 5% of women, mainly postmenopausal women. Gout tends to occur at younger ages. The natural course of gout can be divided into four stages, namely, asymptomatic hyperuricemia stage, acute stage, intermittent stage, and chronic stage [3]. The clinical manifestations are as follows:
1. Acute gouty arthritis
Most patients have no obvious symptoms before the attack, or only have fatigue, general discomfort and joint pain. Typical attacks often wake up in the middle of the night due to joint pain. The pain progressively worsens and reaches a peak around 12 hours. It looks like tearing, cutting or biting, which is unbearable. The affected joints and surrounding tissues are red, swollen, hot, painful, and have limited function (Figure 1). It usually resolves spontaneously within a few days or 2 weeks. The first attack mostly affects a single joint, with more than 50% occurring at the first metatarsophalangeal joint. In the subsequent course of the disease, 90% of patients will have this site involved. Followed by joints such as the dorsum of the foot, heel, ankle, knee, wrist, and elbow. Joints such as the shoulder, hip, spine, and temporomandibular joints are less affected. Multiple joints can be affected at the same time, manifesting as polyarthritis. Some patients may have systemic symptoms such as fever, chills, headache, palpitations, and nausea, which may be accompanied by increased white blood cells, increased erythrocyte sedimentation rate, and increased C-reactive protein.
2． Intermittent attack period
Gout attacks last for several days to weeks and then resolve on their own. Generally, there are no obvious sequelae, or local skin pigmentation, desquamation, itching, etc. may be left, and then enter an asymptomatic intermittent period. Relapse occurs after several months, years, or more than ten years. Most patients relapse within one year, becoming more and more frequent, involving more and more joints, and the symptoms last longer and longer. The affected joints generally develop from the lower limbs to the upper limbs, from the distal small joints to the large joints, and joints such as the fingers, wrists and elbows are affected. A few patients can affect the shoulder, hip, sacroiliac, sternoclavicular or spinal joints, and joints can also be involved. Symptoms tend to be atypical in areas such as surrounding bursae, tendons, and tendon sheaths. A small number of patients have no intermittent period and show chronic arthritis after the initial onset.
3. Chronic tophi disease stage
Subcutaneous tophi and chronic tophi arthritis are long-term and significant hyperuricemia. A large amount of monosodium urate crystals are deposited in the subcutaneous, joint synovium, cartilage, bone and Results in periarticular soft tissue. The typical location for subcutaneous tophi is the auricle (Figure 2). It is also common around recurrent joints and in locations such as the olecranon, Achilles tendon, and patellar bursa. The appearance is yellow-white excrescences of different sizes raised under the skin. The skin surface is thin. After ulceration, white powdery or paste is excreted, which does not heal for a long time (Figure 3). Subcutaneous tophi often coexist with chronic tophi arthritis. A large amount of tophi deposited in the joint can cause joint bone destruction, fibrosis of peri-articular tissue and secondary degenerative changes. The clinical manifestations are persistent joint swelling, pain, tenderness, deformity and dysfunction. Symptoms in the chronic phase are relatively mild, but acute attacks can also occur.
Clinical manifestations of gout (3 photos)
4. Kidney disease
(1) Chronic urate nephropathy: Urate crystals are deposited in the renal interstitium, leading to chronic tubulointerstitial nephritis. Clinical manifestations include decreased urine concentration function, increased nocturia, low specific gravity urine, small molecule proteinuria, leukocyteuria, mild hematuria and cast urine. In the late stage, glomerular filtration function may decrease and renal insufficiency may occur.
(2) Uric acid urinary tract stones: The concentration of uric acid in the urine increases to a supersaturated state, which deposits in the urinary system and forms stones. The incidence rate in gout patients is more than 20%, and may appear before the development of gouty arthritis. Smaller stones are gravel-like and are excreted in the urine and may be asymptomatic; larger stones can block the urinary tract and cause renal colic, hematuria, dysuria, urinary tract infection, renal pelvic dilatation, and hydrops.
(3) Acute uric acid nephropathy: The levels of uric acid in the blood and urine rise sharply, and a large amount of uric acid crystals are deposited in the renal tubules, collecting ducts, etc., causing acute urinary tract obstruction. The clinical manifestations are oliguria, anuria, and acute renal failure; a large amount of uric acid crystals can be seen in the urine. It is mostly caused by secondary causes such as malignant tumors and their radiotherapy and chemotherapy (ie, tumor lysis syndrome).