FAMILY MEDICINE® COLUMN

By John C. Wolf, D.O.Associate Professor of Family Medicine Ohio University College of Osteopathic Medicine

GOUT MOST COMMON IN "BIG TOE," CAN AFFECT ANY JOINT

Question: I've had several episodes when my ankle became very painful and swollen without having an injury to account for this. My doctor has diagnosed me with gout. I thought that gout only caused the big toe to be sore. My big toe has never been a problem. Could I really have gout?

Answer: Gout is a specific form of arthritis, and it certainly can cause your ankle to become sore without affecting your big toe. All types of arthritis cause inflammation of one or more joints. The most common form of arthritis, osteoarthritis, causes inflammation by a poorly understood method. Gout, on the other hand, is understood both on clinical and on biochemical levels. This makes gout a unique type of arthritis. Let's start the story of gout with reference to a meal. Start the repast with an appetizer of liver pâté -- you choose the type of cracker. Follow this with a main course of sizzling T-bone steak accompanied by a liberal amount of red wine.

This meal for someone prone to gout would be like a person with diabetes eating a super-sized banana split with extra sugar sprinkles on the top! That's because each of these delectable victuals contains a gout-inducing chemical component called purines, which are found in abundance in liver, red meat and yeast. Fermented beverages contain yeast, by the way.

Purines can bring on an episode of gout in a susceptible person because of the way they are metabolized. Your body converts purines into uric acid and subsequently eliminates them through the urine. However, individuals with gout have an overproduction of uric acid or a decreased
ability to eliminate it. Either of these situations produces an increased level of uric acid within the blood and other body fluids. Now for another food comparison: I'm sure that you've noticed that
you can only dissolve a few spoonfuls of sugar in your iced tea. Adding more doesn't make the tea any sweeter; it just makes the pile of undissolved sugar on the bottom of the glass larger. This is called a saturated solution.

The blood and body fluids, particularly the fluids around joints, can become saturated with uric acid. Gout is the deposition of uric acid crystals (just like the sugar crystals in the bottom of the tea glass) in body tissues. This is most common in three locations: the kidneys, where uric acid crystals can form kidney stones; around a joint, where the crystals can form irregularly shaped "knots" called gouty tophi; and within a joint space, where too many crystals can produce an acute attack of gout -- just as you have had in your ankle.

Gout has a 20:1 preference for men, and it usually occurs after age 30. Kidney disease, certain cancers, some medicines and even lead poisoning can cause gout too, but the most common cause is the inherited tendency combined with a rich diet and liberal use of alcohol.

The classic attack of gout does involve the big toe, just as you suggested. Regardless of the part affected, an attack of gout is usually confined to one joint and comes on quickly without any preceding injury. The pain and swelling can be severe. As with your ankle, sufferers often experience many episodes of inflammation.

Joints in the foot are most commonly involved in gout. This is perhaps due to the temperature in the foot and the daily pounding these joints endure. Sometimes, though, gout can afflict joints not in the foot and attack several joints simultaneously.

The treatment of an individual with gout includes an anti-inflammatory medicine to quiet the attack of gout. Once the attack has
subsided, medicine to reduce the level of uric acid in the blood is prescribed. Of course, none of this is likely to give lasting freedom from attacks of gout unless there is also a change to more healthy eating habits.

"Family Medicine" is a weekly column.

To submit questions, write to: John C. Wolf, D.O., Ohio University College of Osteopathic Medicine, Grosvenor Hall, Athens, Ohio 45701.

Past columns are available online at http://www.FamilyMedicineNews.org.