Musculoskeletal Ultrasound to diagnose gout definitively during non-acute period

As you rightly point out it depends on the cost. But the cost of the test has to be balanced against the cost of treating someone for 20 years for the wrong disease.

I think you may underestimate gout as a relatively benign condition. The underlying condition of elevated urate and crystals in many tissues, leads to long-term low-level inflammation which will ultimately killthe patient (all be it slowly). The increase mortality rates of those with gout is quite horrible, especially but not exclusively, in respect to heart disease.

Then I must say that diet plays an important aspect of how the condition of high cholesterol develops in gout patients. This would be attributed to those in particular eating sugar, processed and frie d foods. Eating a poor quality diet always seems to be the culprit of rising cholesterol in patients. I worked in the cardiology medical field before I retired and it's always the patients with poor eating habits that have high cholesterol, a few had gout attacks as I recall. Again, lack of blood circulation and consuming sugar were seen as the cause of most attacks in mostly older people in their 60's. My mom has high cholesterol and never had gout, my grandmother, had gout but no cholesterol. So it really depends on the gene factor, if you carry it then you have the predisposition of having both gout and cholesterol. If you don't then you'll just have psuedogout like I have.

I will find the research - but •independent• of other risk factors - gout patients have a (from memory) 209% increased risk of heart attack. The reason is the urate crystalises in the tissues causing long-term inflammation. It may be that the reason that the heart attack lowing effect of allopurinol is simply because it seriously lowers "bad" cholesterol.

So we get more chance of hearth attack ? My cholesterol levels come always fine in test. And since i started the cholcicine and allopurinol im doing very good with no pain

No worries, I just looked it up, and it appears that gout sufferers have a higher incidence of heart disease.

•untreated• gout suffers have higher mortality on a host of diseases; the worst being the heart and circulation.

But remember - gout doesn't give an absolute increase - it just increases the risk - so if your heart attack risk is low, while the risk increase by x% - it's still very low. However remember the risk applies to uncorrected untreated gout.

Does apply to pseudo gout as well?

 

Sorry I have no idea and a search of the literature gave nothing either. (In fact there's seems to be much less research into pseudo gout). However as the diseases are similar, with just a different chemical and crystal, with the crystals encouraging attack by the immune system... if I had to guess I d guess it applies to both.

Ask your doctor?

So why is it that I have been a vegi for 53 years and get gout. You either get it or you don't. Nearly every gout sufferer gets it as a result of genetics. It's NOT the desease of kings, and never has been. YES, a bad diet doesn't help, but if the correct medication is given, diet only plays a small part. 

I must say I agree. At least in my case I have a pretty much ideal diet - but all my cousins on one side of the family have gout.

Diet is just 10-20% of our purine production - the rest is us recycling our dead cells.

Thank you all for the input and insights! I got some update -- 

I went to the rheumatology doctor who wrote that article in Taiwan, (I'm Taiwanese), he was extremely certain that I am too young and almost impossible to get gout since I don't seem to have that kind of gene (none of my immediate family members had it and I'm not a aboriginee). He was fairly certain that my toe and the latest X ray images look like bunion.

I brought up the article he wrote, he did the ultrasound on my toe with a confident look that I was just worrying too much...he then found something at the bottlom side of my toe joint (where I have never felt sore). At that point, he still believed that the additional layer on top of the joint can indicate something else. Finally he drew the fluid and saw crystals. So I am officially a gout patient.

Before him, I saw 3 other doctors (1 internist in the US, 1 podiatrist in the US, 1 other rheumatology doctor in Taiwan), none of them believed my symptoms and my physical condition indicate that I had an gout attack...but the latest test revealed the truth. 

He doesn't think that I need to be on colchicine for too long since my UA isn't that high. He prescribed me with 1-month colchicine and asked me to  watch my diet and have my UA checked on a regular basis, keeping it lower than 6.8, then we'll go from there.

I guess the answer to the big question in this thread is: Yes, Musculoskeletal Ultrasound can be a way to diagnose gout if the symptoms of the attack were very mild, uncommon and that the infected joints were small. However, the ultrasound image still needs to be paired with other typical tests -- blood test and Synovial fluid, etc. 

Good for you that you know exactly what you have, that now you're officially in the Gout club.

 

Hi Amy

Frankly if the person you are seeing is a qualified specialist rheumatologist, then my suggestion would be you find a pilot and go to a doctor outside the country. He is making some very basic mistakes.

1. The reference to keeping the urate level below 6.8 is a mistake that I'd guess would be okay for a first year student. 6.8 is the level at which monosodium urate monohydrate crystals begin to form •at 37C•. However at 35 degrees C (a temperature reached at night in a big toe poked out of a bed cover), monosodium urate monohydrate crystals precipitate. This is why the max reference level healthy level healthy blood urate is 5.9.

However, it is worse than that. For people who •already• have attacks of gout, the tissues are already 'enriched' with urate, which has to be removed. For the crystals all over the body to return back into solution, the level of urate must be substantially below 5.9. The lower the better (from memory the minimum is 2.3; the reason is the flushing happens quicker if it's lower. After you've had no gout for 6 months or so it's safe to go to a higher level (but less than 5.9).

2. He is extremely certain that you are too young to have gout. This is an error a first year med student should not make. As long as you are post puberty, it is perfectly normal for human beings to have gout.

3. Genes. There are many factors which cause gout, genes, urate and previous injury especially to the big toe are three. But research shows it's more complex because there are those with very high urate and no gout, and those with low urate and do get gout. To simply say you don't have the genes for gout is not the kind of remark a qualified specialist should make.

As for the other three doctors not thinking you had gout - how can they know unless they are Superman or have done the test of the synovial fluid? (Although high blood urate is a jolly good indication).

As for the ultrasound it's a waste of time and money.

If the test is negative or positive you still have to rely on the synovial fluid - so why bother?

Based on this doctor my advice is get a plane to Tokyo or Singapore.