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Definitive Diagnosis of Gout by Identification of Urate Crystals in Asymptomatic Metatarsophalangeal Joints.

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BRIEF REPORTS
559
DEFINITIVE DIAGNOSIS OF GOUT BY IDENTIFICATION OF URATE
CRYSTALS IN ASYMPTOMATIC METATARSOPHALANGEAL JOINTS
CARLOS A. AGUDELO, MD, ABRAHAM WEINBERGER, MD, H. RALPH SCHUMACHER, MD, ROBERT
TURNER, MD, and JAVIER MOLINA, MD
Since McCarty and Hollander (1) in 1961 demonstrated monosodium urate cystals in synovial fluids,
crystal identification has come to be regarded as the major diagnostic criterion for acute gouty arthritis (2). In
the interim period between attacks, the diagnosis of
gout is based on either aspiration of visible tophaceous
material that has been reported to exist in about 30% of
patients or suggested criteria (2) that include hyperuricemia and a variety of clinical features.
Thirteen of 14 consecutive patients with a classic
history of gout but without signs of inflammation at the
time of aspiration of the first metatarsophalangeal
(MTP) joint have been found to have monosodium
urate crystals in these aspirates on compensated polarized light microscopic examination (3). One MTP joint
not previously clinically involved was also found to contain crystals. These findings suggest that this simple procedure may be of great help in definitively establishing
the diagnosis of gout in patients not experiencing acute
attacks at the time of examination.
Patients and Methods. Fourteen patients (13 men
and 1 woman) ages 40-80 with typical histories of podagra without apparent tophaceous deposits were studied. Ten patients had had diagnosis confirmed previously by demonstration of monosodium urate crystals
by compensated polarized light microscopy during attacks involving other lower extremity joints. Two patients had been asymptomatic for l year while on colchicine and allopurinol therapy (0.6 mg twice daily and
300 mg/daily, respectively) with serum uric acids of 6.0
and 6.8 mg% (normal 2.5-8 mg). Twelve patients had
documented hyperuricemia in the past; 6 were normouricemic at the time of study.
From the Rheumatology Unit, Department of Medicine,
Bowman Gray School of Medicine, Winston-Salem, North Carolina;
Arthritis Section, University of Pennsylvania School of Medicine and
Veterans Administration Hospital, Philadelphia, Pennsylvania; Instituto de Seguros Sociales, Medellin, Colombia.
Address reprint requests to Carlos A. Agudelo, MD, Rheumatology Unit, Department of Medicine, Bowman Gray School of
Medicine, Winston-Salem, North Carolina 27103.
Submitted for publication January 1 1 , 1979; accepted January 19, 1979.
The first MTP joint was aspirated under aseptic
technique using a dorsolateral approach and topical
anesthesia with chloroethane. The joint was entered
with a 20 or 21 gauge needle attached to a 10 cc syringe.
The minute amount of material that usually included 12 drops of synovial fluid thus obtained was then placed
on a glass slide, a coverslip was applied, and the slide
was examined immediately for the presence of crystals
under regular light and compensated polarized light microscopy. In l patient with a l-year history of gout, both
first MTP joints were aspirated although his left MTP
joint had never been acutely inflamed. Roentgenograms
of the feet were done in 6 patients; 5 of these were normal and 1 showed a MTP cyst.
Results. Fourteen of 15joints aspirated yielded
strongly negative birefringent crystals typical of monosodium urate and were often intermingled with erythrocytes. All crystals seen were extracellular; in 2 cases the
crystals were the long ( 15-2Op) needles seen frequently
in tophi but are rarely found in joint fluid. In the patient
in whom both MTP joints were aspirated, crystals were
demonstrated in each aspirate.
Discussion. Although a history of acute arthritis
of the first metatarsophalangeal joint is typical of gout,
a variety of other diseases including osteoarthritis, Reiter’s syndrome, trauma, and infection can also involve
this joint.
The best way to classify a patient as having
gouty arthritis is to demonstrate characteristic sodium
urate monohydrate crystals in the joint aspirate (2). It
has been known from the postmortem studies of Garrod that urate tophi can occasionally be found in apparently asymptomatic joints (4). Our demonstration that
crystals are almost invariably present in first MTP joints
in the interim between attacks suggests a simple and
useful method for diagnosis of gout in patients not experiencing active arthritis.
Since crystals were still found in two asymptomatic patients after a year of allopurinol therapy despite
normal serum uric acids, it will be of interest to determine how much therapy is needed to deplete joints of
the crystals.
BRIEF REPORTS
5 60
The presence of urate deposits in asymptomatic
joints and in an apparently previously uninvolved joint
raises the question of what factors must change to allow
the crystals to be phlogistic (4,5).
REFERENCES
I. McCarty DJ, Hollander JL: Identification of urate crystals
in gouty synovial fluid. Ann Intern Med 54:452-460, 1961
2. Wallace SL, Robinson H, Masi AT, Decker JL, McCarty
DJ, Yu T: Preliminary criteria for the classification of the
acute arthritis of primary gout. Arthritis Rheum 20:895900, 1977
3. Phelps P, Steele AD, McCarty DJ: Compensated polarized
light microscopy: identification of crystals in synovial
fluids from gout and pseudogout. JAMA 203:508-5 12,
1968
4. McCarty DJ: The gouty toe-A multifactorial condition
(editorial). Ann Intern Med 86:234-236, 1977
5. Schumacher HR: Pathogenesis of crystal induced synovitis.
Clin Rheum Dis 3:105-131, 1977
ERATTUM
In Table 1 on page 85 of the article, “Coexistent Gout and Rheumatoid Arthritis,” by Daniel Wallace et al, the correct numbers should be:
Women with rheumatoid arthritis
Men and women with rheumatoid arthritis
3,360.000
5,145.000
If 3.2% of gouty women had rheumatoid arthritis (52,500 x 3.2%), 1680 concurrent cases
would be expected.
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crystals, metatarsophalangeal, urate, gout, joint, definitive, identification, asymptomatic, diagnosis
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