Arthritis and Other Joint Diseases - Gout

Gout is an arthritic disease associated with an abnormality of body chemistry. There is an excessive accumulation of uric acid in the blood resulting from the chemical abnormality, and the uric acid, in the form of sharp urate crystals, may accumulate in the joints, where they cause an inflammation with symptoms like those of arthritis. A frequent target of theurate crystals is the great toe, which is why gout patients occasionally are pictured as sitting in a chair with one foot propped upon a pillow.

Primary Gout

There are two forms of gout, primary gout and secondary gout. Primary gout is presumed to be linked to a hereditary defect in metabolism and afflicts mostly men, although women may experience the disease after menopause. The painful inflammation may develop overnight following an injury or illness or after a change in eating habits. The patient may suddenly feel feverish and unable to move because of the tenderness of the affected joint, which becomes painfully swollen and red.

Although the great toe is a common site for the appearance of gout, it also may develop in the ankle, knee, wrist, hand, elbow, or another joint. Only one joint may be affected, or several joints might be involved at the same time or in sequence. The painful attack usually subsides within a week or so but it may return to the same joint or another joint after an absence of a few years. The inflammation subsides even if it is not treated, but untreated gout may eventually result in deformity or loss of use of the affected joint. During periods between attacks the patient may show no signs of the disease except for high blood serum levels of uric acid and the appearance of tophi , or urate (a salt of uric acid) deposits, visible in X-ray photographs of the joints.

Secondary Gout

Secondary gout is related to a failure of the kidneys to excrete uric acid products or a variety of diseases that are characterized by over production of certain types of body cells. Failure of the kidneys to filter out urates can, in turn, be caused by various drugs, including aspirin and diuretics. Gout symptoms can also be caused by efforts to lose weight rapidly through a starvation diet, because this speeds up the breakdown of stored body fats. Among diseases that may precipitate an attack of secondary gout are Hodgkin's disease, psoriasis, and some forms of leukemia.

Chronic Gouty Arthritis

A form of arthritis called chronic gouty arthritis is associated with patients who have abnormal levels of uric acid in their blood. While they may or may not be plagued by attacks of acute joint pain, the urate deposits apparently cause a certain amount of stiffness and soreness in various joints, especially during periods of stormy weather or falling barometric pressure. The tophi or urate crystals may spread to soft tissues of the body, such as bursae, the cartilage of the ear, and tendon sheaths. More than ten percent of gout patients eventually develop kidney stones formed from urate deposits in the kidney.

Treatment of Gout

Because gout was traditionally associated with certain meats that are rich in chemicals called purines , special diets were once a routine part of the treatment. In recent years, there has been less emphasis placed on maintaining a low-purine diet for gout patients. This change in therapy is mainly the result of the relatively good success in maintaining proper uric-acid levels in gout patients with medications. However, adequate fluid intake is still recommended to prevent development of urate kidney stones.

Infectious Arthritic Agents

There are at least 12 types of arthritis and rheumatism that are associated with infections involving bacteria, viruses, fungi, or other organisms. One of these diseases is known as pyrogenic arthritis . The arthritis-causing organisms infect a joint and induce pain and fever and limitation of joint movement by muscle spasm and swelling. Treatment includes bed rest and antibiotics. If untreated, destruction of the joints is possible.

Gonococcal Arthritis

This disease is transmitted by the gonococcal bacteria associated with venereal disease. As in the venereal disease itself, the arthritic effects are more likely to be treated at an early stage in men than in women because men are more likely to develop obvious infections of the urethra and thus seek medication from a physician. In females, the initial infection is likely to go unrecognized and untreated by antibiotics. The infection, meanwhile, may spread to body joints and produce acute attacks of arthritis. The symptoms tend to appear first in the wrists and finger joints; there may also be skin lesions that occur temporarily in areas near the joints.

Tuberculous Arthritis

As the name suggests, this disease is associated with tuberculosis and can be serious, leading to the destruction of involved joints. The infection spreads to the joints from other areas of the body. The early symptoms include pain, tenderness, or muscle spasm. In children and young adults the infection tends to settle in the spinal joints. If there is an absence of pain, the disease may go unnoticed until changes in posture or gait are observed. If untreated, the disease may progress toward spinal deformity. When detected early in the course of the disease, treatment with anti-tuberculosis drugs and physical therapy may control the disorder. In some cases, surgery may be required.

Rubella Arthritis

This form of arthritis derives from an infection involving the rubella virus. The arthritis symptoms may appear shortly after a rash appears, or they may be delayed until after the rash has faded. The onset of the arthritis effects may be accompanied by fever and a general feeling of illness; pain and swelling are most likely to occur in the small joints of the wrists, knees, or ankles. The physician usually advises aspirin for the pain while it lasts, usually about a week. Eventually all signs and symptoms may subside without joint destruction.

Bacteria That Cause Arthritis

A type of bacteria that causes spinal meningitis also may cause symptoms of arthritis. The pain usually is not severe and may be limited to a few body joints. Antibiotics are administered to control the infection, although this form of the disease does not respond as rapidly to the medication as some of the other versions of arthritis caused by infection.

Several other kinds of bacteria may invade the joints and precipitate or aggravate arthritic symptoms. They include the increasingly common strains of bacteria that have become resistant to control by antibiotics. Patients who are being treated with steroid drugs or those whose resistance to infection has been lowered by disease are among the most vulnerable victims.

Fungal Arthritis

While fungal infections are relatively rare causes of arthritis, there are at least four kinds of fungus that have been identified as the responsible organisms in joint inflammations. The fungus seems to be carried by the bloodstream to the area of the joint where it causes an inflammation in the tissues surrounding the bony structures. The infection usually can be treated with special antibiotic remedies that destroy fungal organisms, but surgery is occasionally necessary to ensure eradication of the source of the inflammation.

Psoriatic Arthropathy

Arthritis also may be associated with psoriasis (a chronic skin condition marked by bright red patches and scaling) in a disease known as psoriatic arthropathy . This variation of the disease is marked by a deep pitting of the nails along with a chronic arthritic condition. The disease may be mild or very destructive and the sacroiliac region of the spine may be involved. The uric acid levels associated with gout frequently are elevated in patients with psoriasis, so gout symptoms also can appear. Unfortunately, one of the medications commonly used in the treatment of rheumatoid arthritis and gout, chloroquine, cannot be used as therapy for psoriatic arthropathy symptoms because the drug aggravates the psoriasis. Otherwise, the treatment is quite similar to that used for rheumatoid arthritis—analgesics such as aspirin and steroid drugs. In severe cases, methotrexate may be administered to control both the joint and skin symptoms.

Other Arthritic Diseases

Two kinds of arthritis once associated with venereal diseases are no longer considered a hazard of intimate contact. One is syphilis-caused arthritis, which is a possible problem but actually quite rare because of improved control of syphilis. The second is Reiter's syndrome , a form of arthritis in which there is also involvement of urethritis, or inflammation of the urethra, and conjunctivitis, an inflammation of the eye. The disease also may be accompanied by skin lesions and a fever, pain in the heels, and a urethral discharge. Perhaps because Reiter's syndrome seems to affect young men and symptoms may be similar to those of gonococcal arthritis, it was once assumed that this form of arthritis was a kind of venereal disease. However, there is a lack of evidence that the disease is transmitted by sexual contact.

Rheumatic Fever

This generalized inflammatory disease, which affects the entire body with pain and swelling of the joints, sometimes is classified as a form of arthritis. Rheumatic fever usually follows a sore throat or tonsillitis caused by streptococcus bacteria; however, the disease is not regarded as a streptococcal infection by itself. A common effect of rheumatic fever is a scarring of the heart valves due to inflammation of that tissue. The heart valve damage is permanent. The streptococcal infection itself can be controlled by antibiotic medications. For further information, see “Rheumatic Fever and Rheumatic Heart Disease” in Ch. 10, Heart Disease .