Gout and septic arthritis
Dr Wrishi Raphael
Mr Gani, a 65 year old hailing from Uttara presented with pain and swelling of his right knee joint for the last three days. Mr Gani has suffered from gout for the last two years and has been on Allopurinol since then. This sudden flare up of symptoms can lead to the possible diagnosis of two similar conditions which we will discuss today. The first diagnosis could be acute flare up of gout, which is more common in patients like Mr Gani who have suffered from gouty arthritis for a prolonged period of time. The second cause of Mr Ganis swollen knee
maybe septic arthritis which is capable of mimicking symptoms of acute gout.
Gout is a type of arthritis. It occurs when uric acid builds up in blood and causes inflammation in the joints. Acute gout is a painful condition that often affects only one joint. The great toe is a joint which is most commonly affected by gout. Other than the great toe, the most common sites of gouty arthritis are the ankle, wrist, finger joints, and knee. Chronic gout is repeated episodes of pain and inflammation while septic arthritis is inflammation of a joint caused by a bacterial infection. It is also known as infectious or bacterial arthritis.
The condition is most commonly caused by staphylococcal or streptococcal bacteria. Out of the two, acute gout maybe considered the lesser of two evils thats why its vital for clinicians to rule out the more notorious septic arthritis through careful clinical examination and investigation.
The joint pain of septic arthritis often comes with massive swelling, hotness and effusion of the effected joint. Systemic symptoms like fever and malaise may also be present.
Whether or not significant swelling and fluid accumulation has occurred must be thoroughly verified by the clinician and if clinical suspicion cannot be ignored, joint fluid must be aspirated and sent for microscopic examination, culture and sensitivity. Prophylactic antibiotics should be started while lab results are due.
Medical management of infective arthritis focuses on adequate and timely drainage of the infected synovial fluid, administration of appropriate antimicrobial therapy, and immobilization of the joint to control pain. Acute prosthetic joint infection (PJI) can be cured medically if it is of the early type or secondary to hematogenous (blood borne) spread without any evidence of periarticular soft-tissue involvement or joint instability. Overall, the length of hospitalization for septic arthritis can be pretty long if infection and joint disability is severe. However, outpatient antibiotic therapy in stable patients can significantly reduce hospital stays.
If the swelling or effusion is not significant or aspiration reveals the presence of scanty fluid; the possibility of septic arthritis may be ignored. Under such circumstances, it may be inferred that the patient has an acute flare up of gouty arthritis. For any patient of acute gout, pain relief is a primary concern.
Non Steroidal Anti Inflammatory Drugs (NSAIDS) and Colchinine are excellent in pain alleviation and should be administered till the acute flare up of gout subsides. Colchicine is used to prevent gout attacks (sudden, severe pain in one or more joints caused by abnormally high levels of a substance called uric acid in the blood) in adults, and to relieve the pain of gout attacks when they occur.
While treatment for acute gout is ongoing, it is prudent to avoid Allopurinol, however certain authorities have inferred that Alloprinol may be continued in acute gout.
Diagnosing and treating gout or septic arthritis can be a handful as both disorders can produce similar problems. But excluding septic arthritis first hand will take precedence over acute gout for patients of all ages; as acute gout management consists mostly of analgesia and assurance. If antibiotics are not prescribed, septic arthritis may produce debilitating effects. Being able to differentiate between septic arthritis and gout requires good clinical experience and efficient history taking. To be able to perform joint fluid aspiration safely and aseptically also demands training, precision, tact and confidence. All general practitioners must have the professional acumen so that they may be able to differentiate gout from septic arthritis and intervene effectively.
The writer can be reached at
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