Symptoms of Gout

Gout, also known as gouty arthritis, can develop when there is excess uric acid in the body. Symptoms can be sudden and severe, causing pain, redness, and swelling in the affected joint, most often the big toe. Attacks occur most frequently at night or in the early morning hours. If left untreated, recurrent attacks can lead to joint deformity and the progressive restriction of movement.

While the severity of symptoms can vary, gout tends to progress in stages and to worsen over time. By recognizing and treating the symptoms early, you can avoid many of the long-term complications and improve your overall quality of life.

The symptoms of gout can vary by the stage of the disease. Attacks occurring during the early stages can often be mild and manageable, but they tend to worsen with each subsequent attack. 

The three stages are broadly described as follows:

• Asymptomatic hyperuricemia in which there are no symptoms but uric acid crystals are starting to form around a joint
• Acute intermittent gout in which symptoms develop and recur
• Chronic tophaceous gout in which uric acid crystals form into chunky deposits, called tophi, in and around joint spaces, causing persistent inflammation and other long-term complications

Acute Intermittent Gout

Acute gout attacks usually last from three to 10 days, with or without medication. While the pain can strike suddenly, it tends to intensify in the early part of an attack before gradually resolving. Over half of the cases will involve the metatarsal-phalangeal joint at the base of the big toe. Other common sites include the knee, ankle, heel, midfoot, elbow, wrist, and fingers.

Attacks are more likely to occur at night or in the early morning hours. This is due, in part, to nighttime dehydration (which increases the uric acid concentration) and lower body temperatures (which promotes uric acid crystallization).

The most common signs of a gout attack include:

• A sudden and severe joint pain which some sufferers describe as being akin to breaking a bone, getting stabbed with glass, or having a severe burn
• Joint swelling, redness, and warmth triggered by acute inflammation
• Joint stiffness and pain with movement
• Mild fever
• Fatigue

Gout attacks can often occur in clusters when uric acid levels are persistently elevated (a condition known as hyperuricemia). Generally speaking, the first 36 hours will be the most painful, after which the pain will begin to subside, albeit gradually.

Chronic Tophaceous Gout

Chronic hyperuricemia can lead to the extensive formation of tophi under the skin and in and around a joint space. The accumulation of these hard, lumpy deposits can erode bone and cartilage and lead to the development of chronic arthritis symptoms.

Whereas gout is characterized by acute attacks, chronic arthritis is defined by persistent pain and inflammation accompanied by fatigue, anemia, and a general feeling of unwellness. Over time, the joint can become deformed and interfere with mobility and movement.

Even though most tophi will develop in the big toe, around the fingers, or at the tip of the elbow, tophi nodules can appear practically anywhere in the body. In some cases, they can penetrate the skin and cause crusty, chalk-like nodules. They have also been known to develop in the ears, on the vocal cords, or even along the spine. Most are considered harmless unless they affect joint mobility.

The joints and skin are not the only organs that can be affected by gout. Long-term, untreated hyperuricemia can also lead to the formation of crystals in the kidneys and the development of kidney stones.

In severe cases, a condition known as acute uric acid nephropathy (AUAN) may develop, leading to kidney impairment and a rapid reduction in renal function. People with underlying kidney dysfunction are at greatest risk.

The symptoms of AUAN can vary by the degree of impairment but may include:

• Decreased urine output
• High blood pressure
• Nausea
• Fatigue
• Shortness of breath
• Anemia
• Tissue swelling (edema), mostly in the lower extremities
• "Uremic frost" in which urea excreted in sweat crystallizes on the skin

Not everyone with gout will experience worsening symptoms or need urate-lowering therapy. With that being said, if you ignore symptoms or fail to take action to avoid attacks, you may end up causing yourself long-term harm.

People with gout will sometimes think that the prolonged absence of symptoms means that the disease has spontaneously disappeared. This is usually a fallacy. Unless the underlying cause of high uric acid levels is controlled, the disease can advance silently and reap irreversible harm.

To this end, you should see a doctor if:

• This is your first attack. Even if treatment is not prescribed, you might benefit from lifestyle modifications to reduce the risk of future attacks. 
• Your symptoms don't improve after 48 hours or last for more than a week. If you are on therapy, this may be an indication that changes need to be made, including dietary and lifestyle interventions.
• You have a high fever. While a mild fever can accompany a gout attack, a high fever (over 100.4 degrees F) may be a sign of an infection.