Intended for healthcare professionals

Practice 10-Minute Consultation


BMJ 2010; 341 doi: (Published 15 November 2010) Cite this as: BMJ 2010;341:c6155
  1. William E Cayley Jr, associate professor
  1. 1University of Wisconsin Department of Family Medicine, UW Health Augusta Family Medicine Clinic, 207 West Lincoln, Augusta, Wisconsin, WI 54722, USA
  1. Correspondence to: W E Cayley Jr bcayley{at}
  • Accepted 18 October 2010

An 84 year old woman presents with pain, redness, and swelling of the left great toe, which makes it difficult for her to walk. She is concerned about possible gout.

What you should cover

Acute gout usually presents as painful inflammation of a single joint. Podagra (inflammation of the first metatarsophalangeal joint) is the most common presentation. Less common presentations include tenosynovitis, bursitis, entrapment neuropathies, and axial gout with back, neck, or radicular pain.1

Gouty arthritis is caused by deposits of uric acid crystals in joints. Acute attacks may be triggered by local changes in body temperature or pH; trauma; or articular dehydration. Gout can progress through four clinical stages: asymptomatic hyperuricaemia, acute gout with painful arthropathy, interval gout, and chronic tophaceous gout. The presence of hyperuricaemia alone does not necessarily mean that the patient has gout.2

The most important differential diagnosis besides gout to consider for an acutely inflamed joint is septic arthritis, usually associated with joint effusion and positive Gram stain on joint aspirate. Other diagnoses to consider include calcium pyrophosphate dihydrate deposition disease (typically self limited, affecting the knee, and associated with normal uric …

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