Diagnosing Non-Gout Acute Attacks: Beyond Uric Acid Testing

In addition to measuring uric acid levels, what other methods can be used to achieve a definitive diagnosis during an acute attack of non-gouty arthritis?

Hello Dr.
Gao,
Due to my work in the United States, I was unable to return to Taiwan for medical treatment.
On a day when I felt it was serious, I consulted a local internist.
The doctor examined the swollen area and surrounding tissue, asking if it was painful, to which I replied no.
He mentioned that there are many possible causes for the swelling of the big toe, and it appeared to be trauma-related.
However, if I have a history of high uric acid (which was tested at 7.4 two months ago), it could likely be gout.
He also noted that given my body type (161 cm/44 kg) and age, along with no family history, if it were gout, it would be considered rare.
Due to equipment limitations, the doctor did not arrange for invasive testing at that time, so a definitive diagnosis could not be made.
He emphasized that if I were later diagnosed with gout, due to my nulliparity, he would not recommend long-term use of colchicine or other medications to control uric acid, suggesting that dietary management and increased fluid intake would be best.
An X-ray showed no abnormalities in the bones, and the doctor prescribed Naproxen 500 mg and Ranitidine 300 mg to be taken twice daily, advising that if the pain persisted for more than a week, I should see a podiatrist.
After taking the prescribed medication, the swelling reduced significantly, but it has not completely resolved and seems to have plateaued.

For the past three weeks, there has been a noticeable color difference in both big toes (the left big toe shows a lighter red-purple color extending from just below the joint to the top of the foot near the arch, with a slight protrusion at the joint and a color resembling a mild bruise; the area above the joint shows a distinct red patch, and overall, it appears slightly like a mild bunion, with pain when the big toe is pushed slightly to the left.
There is tenderness between the first and second toes.
In contrast, the right big toe shows no similar issues.
Since suspecting gout, I have been drinking over 2 liters of water daily and consuming freshly squeezed vegetable and fruit juices.
After stopping the medication, I began taking dietary supplements aimed at lowering uric acid and preventing gout (extracts from tart cherry, celery seed, black cherry, bromelain, turmeric root), but the condition of that toe has remained relatively unchanged, with only a gradual reduction in pain when moving the big toe to the left.

This situation persisted until the day before yesterday when the same toe began to feel like it was twisted near the joint.
After applying a topical patch, it did not improve the next day.
I thought a hot water soak would help, but after taking a hotter than usual bath in the evening, the toe and joint turned from a light red-purple back to red and swollen (both feet had the same temperature and affected area).
While walking, the same area (the tendon and the side of the big toe) hurt when bent.
A few hours later, the temperature of both feet decreased significantly, returning to a reddish-purple color, and the pain lessened.
This morning, I woke up feeling much better, with only slight pain when bending, almost back to normal.

I would like to ask for your guidance, Dr.
Gao, as I am unsure which specialty to consult—rheumatology, orthopedics, or metabolic medicine? After researching online, I feel that my symptoms do not align with typical gout and could resemble tendinitis, synovitis, or bursitis.
Additionally, I have not fully recovered for a month (whether it’s when bending the joint, the red area beneath the skin, or the noticeable color difference around the joint compared to the normal toe).
This leads me to question whether gout can present this way.
Can gout manifest without the classic symptoms of redness, swelling, heat, and severe pain at rest? Can it cause a long-term faint red-purple discoloration around the joint, or red patches beneath the skin when bending the toe? Why would the joint appear slightly larger than the corresponding joint on the X-ray, which showed no abnormalities?
Thank you for taking the time to read this amidst your busy schedule.

Li, 20~29 year old female. Ask Date: 2016/09/24

Dr. Gao Jiankai reply Internal Medicine

Hello, thank you for your question.
I will summarize my response as follows:
1.
I believe the likelihood of gout is very low, even if you have mild hyperuricemia.
Generally, gout attacks are quite severe, with significant redness, swelling, heat, and pain, often preventing individuals from walking.
This creates a lasting memory, so based on your symptoms, I do not think it is gout.
2.
Early gout attacks tend to be shorter in duration, rarely lasting more than two weeks.
If joint pain persists for over a month, the chances of it being gout decrease.
3.
Gout is more common in middle-aged men, and women typically experience it after menopause, so your risk of developing gout is quite low.
4.
In the early stages of gout, X-rays will not show any changes, so normal X-ray results are not surprising.
5.
The most accurate diagnosis of gout involves aspirating joint fluid to check for the presence of uric acid crystals.
The big toe joint is the smallest joint from which fluid can be aspirated, allowing the physician to examine it.
6.
Based on your description, it is likely that your symptoms are caused by hallux valgus.
I recommend wearing wide, soft-soled shoes and avoiding pointed high heels, as this may be the most fundamental solution.
7.
To confirm gout, it is advisable to consult a rheumatologist.
The Allergy, Immunology, and Rheumatology Department at Changhua Hospital, Ministry of Health and Welfare, is here to assist you.

Reply Date: 2016/09/24

More Info

Diagnosing non-gout acute attacks can be quite complex, especially when symptoms do not align with the typical presentation of gout. In your case, the absence of severe pain, redness, and swelling, along with the prolonged duration of symptoms, suggests that gout may not be the primary concern. Gout is characterized by sudden and intense pain, often accompanied by swelling and redness, particularly in the big toe, but it typically resolves within a few days to weeks.
Given your history of elevated uric acid levels (7.4 mg/dL), it is understandable that gout was considered. However, the fact that you are experiencing symptoms for over a month without the hallmark signs of gout raises the possibility of other conditions. Conditions such as tendinitis, bursitis, or even early signs of osteoarthritis could present with similar symptoms, particularly in the big toe area.
The color changes you describe, including the reddish-purple hue and the tenderness between your first and second toes, could indicate inflammation or irritation rather than classic gout. The fact that your X-ray showed no abnormalities is also significant; gout can sometimes show no changes on X-rays in its early stages, but chronic gout often leads to joint damage that can be seen on imaging.
Your approach to managing your symptoms through hydration and dietary supplements is commendable. Staying well-hydrated and consuming foods that may help lower uric acid levels, such as cherries and celery seed extract, can be beneficial. However, if your symptoms persist, it is crucial to seek further evaluation.

In terms of which specialist to consult, a rheumatologist would be the most appropriate choice. Rheumatologists specialize in joint and autoimmune disorders, and they can perform more specific tests, such as joint aspiration to analyze synovial fluid for uric acid crystals, which would definitively diagnose gout. They can also evaluate for other potential causes of your symptoms, including inflammatory arthritis or other musculoskeletal disorders.

It is also worth noting that while gout is often associated with high uric acid levels, not everyone with elevated uric acid will develop gout. Many individuals can have high uric acid levels without experiencing any symptoms. Therefore, your current symptoms may not be directly related to your uric acid levels.

In summary, while gout is a possibility given your history, the lack of typical symptoms and the duration of your condition suggest that other diagnoses should be considered. Consulting a rheumatologist will provide you with a comprehensive evaluation and the appropriate diagnostic tests to clarify your condition. In the meantime, continue your hydration and dietary management, and monitor your symptoms closely. If you experience any new or worsening symptoms, seek medical attention promptly.

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