Many people know that an excess uric acid in the blood can cause joint pain. However, they usually do not link the cause to gout and pseudogout, which is the medical term to describe a type of arthritis caused by uric acid crystal accumulation.
What basically happens is that uric acid builds up in the articulations, accumulating in uric acid crystals. These crystals interfere with the normal movements of the articulation itself. When they are very large, they may even trigger wear down of the articulation and significant pain.
The difference between gout and pseudogout is that the former is caused by uric acid, and the latter is caused by calcium pyrophosphate crystals. They have similar signs and symptoms, and here they are:
1. Severe pain
There is no doubt that pain is one of the most critical symptoms of gout and pseudogout. Pain is so intense that it stops being a sign and becomes a symptom because it is clearly visible by the doctor that patients are unable to hold their own weight in the affected articulation. It is very tender during a gout attack, and sometimes patients can’t stand having a bed sheet on because it feels uncomfortable. Pain is described as excruciating, and the onset is abrupt and spontaneous. There’s no apparent trigger, and it usually manifests at night, sometimes in the early hours. The sudden onset of a gout attack is followed by a gradual increase in articulatory pain. The maximum intensity happens within 8 to 12 hours, in which articulations are usually tender, reddened, and hot, as we will cover later in this article. In most cases, the most severe pain only lasts for a couple of hours, and it completely resolves in one or two weeks. In other cases, the symptoms occur over a period of several days with a more insidious onset.
2. Monoarticular arthritis
This is the clinical term that describes inflammatory joint pain located in only one articulation. That is what happens in gout, at least in the first stages of the disease. The pain in gout is usually located in the great toe, but other sites can also be affected. It may take a second articulation, but usually not a third. Thus, it is called acute monoarticular arthritis. Gout has the particularity of happening in episodes or attacks. The pain is not continuous. Instead, it comes and goes in periods of around one or two weeks and usually affects the same articulation. Even when left untreated, the pain resolves in a few weeks. After receiving treatment, it will subside faster.
3. Arthritis in other articulations
As the disease progresses, the acute monoarticular pattern of the disease starts to change. Instead of affecting one articulation, gout now affects two or more. This is called polyarticular arthritis, which means arthritis located in different articulations. It is sometimes symmetrical, which means that both toes, ankles, fingers, knees, or wrists are affected. Various articulations can be taken, but the least likely is the shoulder’s glenohumeral joint. Large joints are the more likely to be affected after the toe. In the late stage of the disease, patients develop chronic polyarticular arthritis. The pattern changes, and instead of having episodes and attacks, the pain has an irregular pattern that turns into a long-standing and chronic condition. In this stage, it is very similar to rheumatoid arthritis because it involves both articulations on each side and is associated with the deformation of the articulations.
4. Inflammation and edema
One of the reasons why gout is so painful is because there is an active inflammatory process in the articulation. The uric acid crystals create erosion in the articulation and damage to the joint ends. This triggers an inflammatory response localized in the trouble area, which worsens the pain and causes even more complications. One of the alterations caused by inflammation is edema. This is an accumulation of liquid in the deep layers of the skin. Edema results from cardiovascular changes in the small arteries triggered by inflammatory cytokines. There is an insufficient venous return, especially in the lower limbs, and the feet look swollen and increased in size. Swelling is worse in the affected articulation. It is more severe in worse cases of gout and pseudogout. However, some patients can experience very severe pain with no noticeable edema.
5. Redness and temperature changes
This is another symptom associated with inflammation, just like edema. What happens is that inflammation changes the way circulation works. Inflammatory cytokines impair venous return and create vasodilatation in small arteries close to the skin. These small arteries are filled with blood, which changes the color and temperature of the skin. The color changes because it adopts the same color as the blood. The temperature increases because it adopts the natural temperature of the blood. Redness and temperature changes are limited to the affected articulation and immediately around it. It is a sign of inflammation and happens in other types of arthritis, too. Temperature changes are more evident during acute attacks. But even in chronic conditions, they can still develop.
6. Stiffness
During a gout attack, the pain can be very intense, and there’s a significant limitation in the movement of the affected articulation. Stiffness is experienced in the same painful articulation. It happens because the uric acid crystals interfere with the normal functioning of the articulation and create an obstacle to the movements. Moreover, as noted above, uric acid crystals will also create erosion in the articulation and inflammation with significant pain. These symptoms will contribute to stiffness because patients feel tenderness in the articulations when they try to move them.
7. Podagra
This is also an important manifestation of gout. Around 50% of patients with gout will also have podagra to a certain degree. If they are not adequately treated and leave the problem unsolved, the incidence of podagra may reach 90%. We have reviewed different gout symptoms above, but podagra joins them all at the same time. It is a combination of severe pain, redness and swelling, temperature changes, and stiffness in the same articulation. Podagra only refers to these manifestations in the big toe. More specifically, in the metatarsophalangeal joint. Most of the uric acid crystals are deposited in this articulation, and it is the most commonly involved in gouty arthritis. Podagra is usually sudden, and the attack starts at night. Without treatment, your organism may resolve the flare by itself, but it sometimes takes up to 10 days to fully resolve.
8. Fever
During a gout attack, you’re also likely to experience fever. This is an increase in body temperature, and it is usually mild or moderate. Fever is independent of temperature changes in the affected articulation, which also happens in gout. Fever in gout occurs in response to the intense inflammation endured by the articulations in your feet. It is very severe, and there’s an acute release of inflammatory mediators into the blood. When received by the brain centers, it will be taken as a sign of infection, and the body raises the temperature to solve the problem. This symptom is usually resolved with the same painkillers used to treat pain in a gouty attack.
9. Chills
When there’s fever, we can sometimes experience chills, too. This is a typical symptom of gouty arthritis, especially in acute attacks and when the fever reaches its higher levels. Chills constitute an attempt to increase body temperature in the organism. After receiving inflammatory signals, the brain changes the temperature threshold. It’s like the brain is receiving alerts that the body is too cold, and you start shivering or trembling. This creates body heat, which is the goal of the sudden jerking movements in your muscles.
10. Malaise
Naturally, patients with severe pain do not feel comfortable or healthy at all. Malaise is a sensation of not feeling well, but not because there is something specifically wrong with your health, like the articulations. Instead, it is a diffuse sensation of feeling unwell, and it is usually related to low energy levels. The sensation of malaise reported in patients with gout and pseudogout can also be described as fatigue and tiredness. This is common in many pain syndromes, and it is characterized by a sensation of weakness and exhaustion, even after resting correctly. It happens because the body is under significant stress as a result of enduring the symptoms. There are sometimes heartbeat changes and usually metabolic and immune system changes that take up a great deal of energy. The sensation can be severe in acute attacks or turn into a lingering sensation of feeling unwell with flu-like symptoms in case of chronic gout.
11. Carpal tunnel syndrome
As noted in other parts of the article, the most commonly involved articulation is the metatarsophalangeal joint. This is basically the big toe joint in one or both feet. But other articulations can be taken instead. Some patients develop carpal tunnel syndrome instead of the usual pain symptoms described above. The carpal tunnel provides tight access to the nerves and tendons to the inside of the hand. The space is limited, and even a slight reduction can cause numbness, pain, and other carpal tunnel syndrome symptoms. In gout, uric acid crystals create structures inside the carpal tunnel and compromise space availability. The median nerve is usually affected, causing pain in your hands, a tingling sensation, and other symptoms. The movement can also be compromised as flexor tendons are involved.
12. Cellulitis-like symptoms
Gout and cellulitis are often misdiagnosed. It is probably one of the most important differential diagnoses to make in these cases. Cellulitis and gout can coexist in the same patient, but they are more likely separate entities and not cross-linked with one another. The difference between gout and cellulitis in terms of signs and symptoms is that gout has an acute presentation, and cellulitis is an insidious infection with gradually worsening symptoms. They both feature erythema or redness, temperature changes in the affected area, and pain. In both cases, patients can have a high white blood cell count, and both will develop fever, which is consistent with the diagnosis of infectious diseases.
13. Heberden and Bouchard nodes
Two distinct nodes form in patients with gout. Heberden nodes are found in the distal interphalangeal joints, and Bouchard nodes affect the proximal interphalangeal joints. They both form in the fingers but at different levels and are signs of degenerative joint disease, especially osteoarthritis. These nodes are basically bony enlargement, known clinically as exostosis. There is a genetic predisposition to developing these nodes, which explains why some patients have them and others do not. It apparently happens because the cartilage between the joints breaks down, and bone spurs develop between bone ends. The joint undergoes erosion and inflammation, causing a rupture in the capsule and synovial liquid leakage.
14. Tophi
Like Heberden and Bouchard nodes, tophi are growths or nodules that usually develop around the affected articulation or close to it. They are large bumps and are made of uric acid crystals. Tophi can form in the cartilage or bone and are not only found in one place. They can be on your feet, elbows, or hands. In some cases, they do not even form around an articulation. For example, they can be found on the outer edge of the ear. They are external, and you can see them as a lump in your skin. Tophi are not painful by themselves, but they can be infected and turn very painful. It is mainly an aesthetic problem but signals bone erosion and possible cartilage destruction as a part of gout.
15. Food-related flare-ups
Another characteristic of gout attacks is that they are often triggered by certain foods or drinks. Gout triggers are usually foods and beverages that increase uric acid levels in the body. They include red meat, seafood, sweetened beverages, and alcohol. In some cases, medications such as aspirin and diuretics can also trigger a gout attack. Every person is different, and your food triggers can be different from anyone else. Thus, as a part of living with gout, you’re prompted to learn about your own body and how it reacts to your everyday choices. In many cases, learning about your triggers can help you reduce the frequency and intensity of gout attacks to the minimum.
16. Renal colics and kidney stones
Uric acid crystals do not only form in the joints. They can also develop in the kidneys, causing kidney stones, especially if you already have a propensity to have them. The urine in patients with gout tends to be more acidic. This, combined with the higher uric acid level in the blood, makes them at risk of developing nephrolithiasis. Uric acid kidney stones are equally hard but with a dark color. If you have them, you’re likely to develop other signs and symptoms, including renal colic (low back pain), urinary outflow obstruction, and urinary infections when they move and tear the urinary tract on their way out.
17. Hematuria and other kidney diseases
When the kidneys are overwhelmed with uric acid, they may also suffer from uric acid nephropathy. In severe cases, these patients may develop progressive renal failure, hypertension, and other problems related to renal insufficiency. Hematuria is a common symptom in these patients, along with dysuria, flank pain, and changes in urinary frequency. Patients are at a higher risk of kidney disease as a gout complication if they have diabetes or hypertension.
18. Metabolic problems
Patients with gout are also at a higher risk of metabolic issues, especially if they already have renal insufficiency. But even if they don’t, there’s a higher risk of metabolic syndrome, also known as pre-diabetes or insulin resistance. The metabolic syndrome is usually one step from type 2 diabetes and features blood lipid imbalances, hypertension, obesity, and a higher cardiovascular risk.
Eye involvement
Gout patients can also develop various ocular abnormalities. This happens because uric acid crystals form tophi in different parts of the ocular surface. They can have subconjunctival vesicles, ocular hemorrhage, and vascular changes in the eyes.
Gout treatment in response to the symptoms above has three phases. In the initial phase, the most important goal is treating the acute attack. In the second phase, patients should receive prophylaxis to reduce the onset of new acute episodes. In the third phase of the treatment, patients receive treatment to lower urate levels, which also reduces the frequency and severity of the symptoms.
Diet and physical activity modifications are perhaps the most critical changes patients can make by themselves. They should reduce the consumption of high-purine foods such as sardines, mussels, and organ meats. Besides purine restriction, patients are encouraged to avoid alcoholic drinks, sodas, and sweetened drinks. They should stay hydrated adequately with a minimum of 8 glasses of water every day and keep watch on their cholesterol levels. Another helpful change you can make is increasing your activity levels and trying to lose weight if you are overweight or obese. However, keto diets and intermittent fasting are not recommended as weight-loss strategies for gout patients.