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The authors briefly describe the history of gout, mainly focusing their attention on the renal involvement. They report some works and theories on gout of great ancient physicians, such as Paracelsus, Sydenham, Boerhaave, Van Swieten and Morgagni.
Gout may be associated with renal disease in two situations: (i) when the abnormal urate metabolism is the primary phenomenon and renal disease occurs secondary to this; or (ii) when the intrinsic renal disease is primary, and results in secondary abnormalities of renal function. Kidney damage secondary to gout is associated with urate deposits either in the intersitium as microtophi or as uric acid crystals within tubules, and vascular disease and infection are superimposed. Hyperuricaemia is a frequent sequel to parenchymal renal disease, but gouty arthritis develops only when the hyperuricaemia is unusually severe. Urate metabolism alters when renal excretion of urate is reduced. The management of these problems is discussed.
A prevalence of hyperuricemia of 50% and of acute gouty arthritis of 20% has been observed in a group of patients with Bartter's syndrome. All patients except one presented initially with complaints unrelated to uric acid metabolism. The cause of their hyperuricemia and subnormal clearance of uric acid is unexplained. Systemic alkalosis, a prominent feature of Bartter's syndrome, can decrease the clearance of uric acid and may contribute to the hyperuricemia and gout that have been observed. Physicians should be aware of the possibility of gout as a clinical complication of Bartter's syndrome and of the inhibitory effects of alkalosis on urate clearance.
Gout and rheumatoid arthritis are relatively common entities individually; however, the coexistence of these two conditions has been reported rarely in the literature. The authors present a case that was followed for 20 years. The patient was seen by the acknowledged internist and podiatrist. Criteria for the evaluation and diagnosis of each disease entity are discussed and correlated to the case reported. Various theories and research attempting to explain the negative coexistence of gout and rheumatoid arthritis are presented.
Visceral gout is reported for the first time in a rough legged hawk (Buteo lagopus). Urate crystals were present on the pericardium, thoracic and abdominal air sacs, and the ventral surface of the liver. The liver and spleen also had urate crystals throughout the parenchyma. There was no indication of articular or renal involvement. The immediate cause of death in this hawk was not identified, but appeared to result from multiple factors, including the visceral gout.
OBJECTIVE: To evaluate the prevalence of hyperuricemia in Taiwan. METHODS: A multi-stage stratified sampling scheme was used in Nutrition and Health Survey, which was conducted in Taiwan between 1993 and 96. Complete biochemical and questionnaire data for 2754 males and 2953 females aged 4 years and older were included in the analysis. The colorimetric enzymatic method was used to measure plasma uric acid in fasting blood samples. Information on self-reported, physician-diagnosed gout was also obtained. RESULTS: The uric acid values of males were found to reach a peak between the ages of 13 and 18 and decrease slightly after 18. The uric acid values of females were stable before the age of 18, decreasing slightly between 19 and 44 years, and increasing in the mid to older age groups (> or = 45 years). Twenty-six percent of adult males (> or = 19 years) and 22% of older males (> or = 45 years) either had hyperuricemia (serum uric acid > 458.0 microM or 7.7 mg/dl) or were taking medication for it. Seventeen percent of adult females and 23% of older females either had hyperuricemia (serum uric acid > 392.57 microM or 6.6 mg/dl) or were taking medication for it. Both adult males and females in mountainous areas, who were primarily aboriginal, had the highest prevalence of hyperuricemia (> 50%) among the 7 survey areas. Mean body mass index (BMI), alcohol consumption, and prevalence of gout were among the highest in mountainous people compared to all included in the study. Multivariate analysis showed that mountainous area, age and BMI are important factors associated with hyperuricemia in males, whereas mountainous area, Class II townships, and BMI are the factors associated with hyperuricemia in females. CONCLUSIONS: We found a high prevalence of hyperuricemia in Han Chinese in Taiwan despite a lack both of obesity and high alcohol consumption. Mountainous people (mainly aborigines) in Taiwan have an even higher prevalence of hyperuricemia, which cannot be completely explained by obesity and alcohol consumption. Genetic components and other environmental factors may have contributed to this pattern of hyperuricemia.
Statistics on the frequency of coronary insufficiency in patients with gout are contradictory. Nevertheless, it is shown that a correlation often exists between attacks of gout and attacks of angina or acute ischaemic episodes. Finally, these anatomo-clinical studies prove the reality of the gouty heart if only because of the discovery of deposits of intracardiac urates.
OBJECTIVE: Previous studies have demonstrated that the lower renal excretion of urates in patients with hyperuricaemia is inversely related to plasma very low-density lipoprotein (VLDL) levels, and the different genotypes of the apolipoprotein E gene are related to the plasma levels of lipids. The aim of this study was to determine the prevalence of apolipoprotein E in hyperuricaemic patients and to investigate whether the renal excretion of urates is conditioned by the apoliprotein E genotype. METHOD: The plasma levels of lipoproteins, cholesterol, triglycerides and uric acid, and the renal excretion of uric acid were studied in 68 patients with gout and in another control group of 50 healthy subjects. Both groups were genotyped for apolipoprotein E by means of an amplification technique and inverse hybridization. RESULTS: The prevalence of the E2 allele was greater in the patients than in the control group. The levels of cholesterol, triglycerides and uric acid were greater in the patients, whereas the levels of high-density lipoprotein were lower. The patients with the E2 allele had higher levels of triglycerides in VLDL and intermediate-density lipoproteins and a lower renal excretion of urates. CONCLUSIONS: These results show that the reduced renal excretion of uric acid in patients with gout is mediated by high levels of VLDL and by the high prevalence of the E2 allele of apolipoprotein E.
Lasting normalisation of uric acid levels after treatment of patients with gout and hyperuricaemia with a combination of 300 mg allopurinol and 60 mg benzbromarone A total of 210 patients (163 men, 47 women) with gout and hyperuricaemia was treated for three months with daily doses of 300 mg allopurinol and 60 mg benzbromarone. During the course of treatment, the uric acid levels decreased to 4.3 +/- 1.3 mg/dl in male, and 4.4 +/- 1.3 mg/dl in female patients. Both of these levels differ significantly from the initial levels (p less than 0.001). Three months after discontinuation of treatment, uric acid levels were 5.7 +/- 1.2 mg/dl in women, and 5.9 +/- 1.4 mg/dl in men, levels that again differed significantly from the initial levels (p less than 0.001); both levels were, however, within the therapeutic range of below 6.4 mg/dl.
AIM: To examine gastric biopsies with polarization microscopy for detection of sodium monourate crystals (SMC). MATERIAL AND METHODS: The trial included 20 patients with gout diagnosis (mean age 55.7 years, mean duration of the disease 12.3 years) in whom esophagogastroduodenoscopy was made with biopsy of gastric mucosa from the antral part of the stomach and middle third of the gastric body. RESULTS: Crystals in the biopsy specimens were detected in 11 of 20 examinees. The crystals were characterized by strong double refraction, length 3-20 mcm, acicular or planiform shape, blue or yellow color depending on position in compensated polarized light. Quantitative distribution of the crystals within one biopsy specimen was uneven and varied from solitary crystals to clusters of 70-80 crystals in sight, up to formation of tophus-like structures. Clinical picture in detection of SMC was characterized by more frequent occurrence of cases with subcutaneous tophuses of various location combined with higher hyperuricemia. CONCLUSION: One of the essential lines in the research of gout concerns mechanisms of SMC formation in organs and tissues and microcrystalline gastroduodenal inflammation. Methods of correction of this inflammation are to be designed.
We report a case of definite rheumatoid arthritis and co-existing gout. Although gout and rheumatoid arthritis are relatively common entities individually, the co-existence of these two conditions is rare.
This treaty on gout is the volgarizzamento of a Latin treaty, De Arthetica passione, which follows the method of the Consilia: analysis of symptoms, definition of the cause and diagnosis. It looks for signs of the illness that are easily recognisable, even by a non-expert, and presents practical rules, in which the symptoms and the cause of the illness appear related. Given that gout can be caused by simple or mixed humours, the author establishes a highly instructive correlation in colour-symptom pairing in order to teach how to correctly undertake a diagnosis.
Gout is one of the oldest known diseases. The term derives from the Latin "gutta", which means "a drop" This word expresses and describes, as no other term can, a method of interpreting the pathologies that have been with us for more than 2000 yrs. The theory of humoral disturbance goes back to the time of Hippocrates. This paper is a historical review of gout, with particular attention given to the interpretation of the origins of clinical, articular and renal involvement allowing us paradigmatically to sum up all the stages in the evolution of the etiopathogenetic and nosographic concepts of medicine through the ages.
Acute gouty arthritis typically presents with a sudden and severe exquisitely painful joint, most classically in the first metatarsophalangeal joint (toe). Demonstrating the presence of monosodium urate (MSU) crystals in the joint fluid or tophus has been the gold standard for the diagnosis of gout. However, many physicians do not perform synovial fluid analysis. In the absence of demonstrating the presence of MSU crystals in aspirated joint fluid or tophus, clinical, radiologic, and laboratory criteria are helpful. This article presents an overview of the various classification criteria, clinical presentations, and laboratory and radiologic studies needed to make the diagnosis of gout.
OBJECTIVE: The absence of accepted standardized methods for monitoring tophaceous gout limits the ability to track tophus progression or regression. This multicenter study assessed intra- and interrater reproducibility of a simple and direct physical measurement. METHODS: The quantitative evaluation was the area (mm2) of each measurable tophus and was determined independently by 2 raters on 2 occasions within 10 days. Intra- and interrater reproducibilities were determined by calculating mean differences and average percentage differences (APD) in measurements of areas for the same tophus at each of 2 visits and by each rater, respectively. RESULTS: Fifty-two tophi were measured in 13 subjects: 22 on the hand/wrist, 16 on the elbow, and 14 on the foot/ankle. The mean (+/- SD) difference in tophus areas between visits was -0.2 +/- 835 mm2 (95% CI -162 to 162 mm2) and the mean (+/- SD) APD was 29% +/- 33%. The mean (+/- SD) APD between raters was 32% +/- 27%. The largest variations in measurements were noted for elbow tophi and variations were least for well demarcated tophi on the hands. CONCLUSION: This simple and reproducible method can be easily utilized in clinical trials and in practice as a measure of efficacy of urate-lowering treatment in tophaceous gout. Among factors contributing to variability in these measurements were the anatomic site of tophi and rater experience with the method. Restriction of measurements to well circumscribed hand or foot tophi could improve reliability, but major changes, as expected with effective therapy, can clearly be documented with this simple technique.
Gout must be regarded as a systemic and chronic disease with potentially serious sequelae. Hyperuricemia is probably an independent risk factor for cardiovascular diseases, at least in high-risk individuals. Nevertheless, current data do not justify for the moment the treatment of asymptomatic hyperuricemia. Finally, if allopurinol remains the only available agent in Switzerland for the treatment of chronic gout, new molecules, like febuxostat and pegylated uricase, are currently being evaluated.
AIM: To evaluate metformin efficacy and safety in patients with gout and insulin resistance (IR). MATERIAL AND METHODS: The trial included 26 patients with gout (criteria of the American collage of rheumatologists) and IR (index HOMA). The inclusion criteria were the following: absence of antigout therapy, normal hepatic and renal function, rejection of alcohol. The drug dose was 1500 mg/day. The study was made of anthropometric and clinical characteristics, 24-h blood pressure monitoring, blood tests for uric acid, glucose, insulin, urea, creatinin, alaninaminotransferase, aspartataminotransferase, lipid spectrum at the first and further visits. RESULTS: A 6-month metformin therapy significantly changed the levels of glucose, insulin, HDLP and LDLP cholesterol, uric acid, HOMA index. Normouricemia was achieved in 11 patients, a significant lowering of uric acid--in 12 patients. The number of affected joints in 23 patients reduced from 4 (1-5) to 1 (0-2), p < 0.01. Seven patients with achieved normouricemia had no arthritis attacks. In 3 of 10 patients with chronic arthritis joint inflammation persisted. Six patients had dyspepsia during the first week of therapy, 1 patient discontinued the drug because of persistent diarrhea. CONCLUSION: Metformin therapy is safe. It reduces IR. The principal result of the study was lowering of uric acid and attenuation of the articular syndrome.
Gout, a chronic hyperuricemic crystal induced arthropathy, may produce soft tissue masses (tophi). Tophi may be found in synovial membranes, periarticular ligaments, tendons, soft tissues as well as internal organs. We present a case in which diagnosis of gout was made by fine needle aspiration of tophus. The patient had a painless nodule over right ankle which was progressively increasing in size. He gave a past history of painful arthropathy, but serum uric acid levels were within normal limits. At this juncture, FNAC of the ankle tophus was performed which revealed aggregated and innumerable dissociated needle-shaped negatively birefringent crystals of monosodium urate (MSU) on polarization microscopy.