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Gout - Making a diagnosis
Investigations

  • No initial investigations are required when managing people with gout-like symptoms.
  • The following tests may be considered as part of ongoing follow up of people with gout-like symptoms:
    • Joint fluid microscopy and culture:
      • Aspiration of joint fluid is not indicated unless the diagnosis of gout is in doubt or septic arthritis is suspected.
      • Presence of urate crystals confirms a diagnosis of gout.
      • Absence of evidence of infection rules out septic arthritis.
      • A review rated the quality of evidence supporting the use of microscopy to detect urate crystals as 'bronze'. No randomized controlled trial (RCT) has studied the effect on clinical outcomes of testing for urate crystals in synovial fluid or tophi. The test can have false positives and false negatives, and the quality of the test depends on the quality of both the laboratory providing the test and the specimen sent for testing [Schlesinger and Schumacher, 2004].
    • Serum uric acid (SUA) or plasma urate is usually measured 4–6 weeks after an acute attack of gout to confirm hyperuricaemia:
      • In the UK the upper limit of the reference range for SUA is usually taken as 420 micromol/L for males, and 360 micromol/L for premenopausal females.
      • Hyperuricaemia may be present without gout. The presence of hyperuricaemia does not equate with a diagnosis of gout as most people with hyperuricaemia do not develop gout.
      • Gout may be present without hyperuricaemia — this is particularly common during the acute attack when plasma urate levels may fall. A Dutch national guideline suggested that a SUA level below 330 micromol/L during an acute attack may be a safe cut-off to exclude gout [Dutch College of General Practitioners, 2004], however this value is not universally accepted.
    • Joint X-ray:
      • Consider X-ray of an affected joint (especially wrist or knee) to look for chondrocalcinosis (calcification of cartilage within joints, which can be associated with gout) [Bencardino and Hassankhani, 2003].
  • Blood tests such as renal function, cholesterol level and fasting blood glucose may be appropriate if clinically indicated.

[Cohen and Emmerson, 1998; Nuki, 2002; Dutch College of General Practitioners, 2004; Schlesinger and Schumacher, 2004]

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