Acute Gout (Monoarthritis)
First MTP Joint Pain • Acute Monoarthritis • Crystal Arthropathy • MRCP (UK) PACES
A structured MRCP (UK) PACES approach to patients presenting with acute monoarthritis due to gout. Learn how to recognise podagra, differentiate gout from septic arthritis and pseudogout, identify secondary causes and explain management confidently in the Long Clinical Consultation station.
At a Glance
PACES Approach
Red Flags
Acute Monoarthritis Framework
Think gout
Exclude sepsis
Consider pseudogout
Fracture or haemarthrosis
Psoriatic arthritis
Reactive arthritis
Overview
Acute gout is the commonest inflammatory crystal arthropathy and typically presents as a sudden, intensely painful monoarthritis affecting the first metatarsophalangeal joint (podagra). The principal objective in the PACES Long Clinical Consultation is to recognise the characteristic presentation while urgently excluding septic arthritis, identifying secondary causes of hyperuricaemia, and counselling the patient regarding both acute treatment and long-term prevention. :contentReference[oaicite:1]{index=1}
Focused History
Characterise the Pain (SONE)
- Site – Which joint is affected? First MTP joint, ankle, knee or elsewhere?
- Onset – Sudden or gradual?
- Nature – Severe pain, redness, warmth and swelling?
- Exacerbating factors – Movement, weight-bearing or touch?
- Relieving factors – Rest, NSAIDs or colchicine?
- Previous similar attacks?
Associated Symptoms
- Fever or rigors
- Night-time onset of pain
- Reduced mobility
- Difficulty walking or weight-bearing
- Skin redness
- Joint stiffness
Identify Secondary Causes
- Chronic kidney disease
- Hypertension
- Diabetes mellitus
- Obesity
- Psoriasis
- Lymphoproliferative disorders
- Recent chemotherapy or tumour lysis syndrome
Medication History
- Thiazide or loop diuretics
- Low-dose aspirin
- Cyclosporine
- Pyrazinamide
- Ethambutol
- Previous colchicine or allopurinol use
Lifestyle History
- Alcohol intake
- Purine-rich diet (red meat, seafood)
- Recent dehydration or fasting
- Smoking history
- Occupational impact
- Family history of gout
Focused Examination
- Inspect the affected joint for erythema and swelling.
- Assess local warmth using the dorsum of the hand.
- Identify marked tenderness.
- Assess active and passive movement.
- Look for joint effusion if the knee is affected.
- Inspect ear pinnae for gouty tophi.
- Look for tophi over fingers, elbows and Achilles tendons.
- Assess blood pressure and body mass index.
- Look for signs of chronic kidney disease.
- Examine for psoriasis or other inflammatory arthropathies.
Differential Diagnosis
Investigations
Baseline Blood Tests
- Full blood count
- CRP and ESR
- Renal function tests
- Serum urate (may be normal during an acute attack)
- Blood cultures if sepsis is suspected
Joint Aspiration (Gold Standard)
- Needle-shaped monosodium urate crystals
- Negative birefringence on polarised microscopy
- Gram stain
- Culture and sensitivity
- Cell count
Imaging
- Plain radiographs if diagnosis is uncertain or chronic disease is suspected
- Typical punched-out erosions with overhanging edges in chronic gout
- Ultrasound may demonstrate the double contour sign
PACES Tip: A normal serum urate level during an acute attack does not exclude gout. If septic arthritis is a possibility, joint aspiration should not be delayed. :contentReference[oaicite:1]{index=1}
Diagnosis
Acute Gout (Podagra)
The sudden onset of an intensely painful, hot, swollen first metatarsophalangeal joint, particularly in a patient with recognised risk factors for hyperuricaemia, is highly suggestive of acute gout. Nevertheless, septic arthritis must always be excluded before confirming the diagnosis or administering intra-articular corticosteroids. :contentReference[oaicite:2]{index=2}
Explaining to the Patient
"Your symptoms are most consistent with gout, which occurs when uric acid crystals collect inside a joint and trigger sudden inflammation. This causes the severe pain, swelling and redness you are experiencing. We will perform investigations to confirm the diagnosis and, importantly, to make sure there is no infection inside the joint, as that requires urgent treatment. Once the diagnosis is confirmed, we can treat this attack and discuss ways to reduce the risk of future episodes."
Management
Examiner's Corner
Why does acute gout occur?
- Persistent hyperuricaemia leads to deposition of monosodium urate crystals within joints.
- Crystal shedding triggers an intense neutrophilic inflammatory response.
- This produces sudden severe pain, erythema, warmth and swelling.
How is gout confirmed?
- Joint aspiration is the diagnostic gold standard.
- Needle-shaped monosodium urate crystals demonstrate strong negative birefringence under polarised microscopy.
- Always send aspirated fluid for Gram stain and culture if septic arthritis is a possibility.
What are the indications for long-term urate-lowering therapy?
- Two or more attacks each year.
- Tophaceous gout.
- Chronic kidney disease.
- Urate nephrolithiasis.
- Radiographic evidence of gout-related joint damage.
How do gout and septic arthritis differ?
| Feature | Acute Gout | Septic Arthritis |
|---|---|---|
| Onset | Sudden | Sudden |
| Fever | May occur | Common |
| Joint aspiration | Monosodium urate crystals | Organisms on Gram stain/culture |
| Treatment | Anti-inflammatory therapy | Urgent antibiotics ± surgical drainage |
Common PACES Viva Questions
- What precipitates an acute gout attack?
- Can serum urate be normal during an acute attack?
- Why is septic arthritis an important differential diagnosis?
- How would you manage a patient unable to take NSAIDs?
- When should urate-lowering therapy be considered?
- What lifestyle advice would you provide?
- Which medications commonly increase serum urate?
Important Clinical Pearls
- Podagra is the classic presentation of acute gout.
- A normal serum urate level does not exclude acute gout.
- Never overlook septic arthritis in a hot swollen joint.
- Joint aspiration provides both diagnostic confirmation and exclusion of infection.
- Long-term prevention is as important as treating the acute attack.
Pathfinder Pearls
Common Pitfalls
- Failing to consider septic arthritis in any acutely inflamed joint.
- Relying solely on serum urate levels to make or exclude the diagnosis.
- Not aspirating the joint when infection is possible.
- Ignoring medications such as thiazide diuretics that contribute to hyperuricaemia.
- Providing acute treatment without discussing long-term prevention.
- Missing chronic kidney disease or cardiovascular comorbidities.
Key Take-home Messages
- Acute gout is the commonest inflammatory monoarthritis.
- Always exclude septic arthritis before confirming the diagnosis.
- Joint aspiration remains the diagnostic gold standard.
- A normal serum urate concentration does not exclude an acute attack.
- Long-term management should reduce future attacks through urate-lowering therapy when indicated and appropriate lifestyle modification.
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