Gout in Women – a Diagnostic Challenge

Abstract

Objectives Gout predominantly affects men (male: female; 9: 1). The clinical presentation of acute monarthritis of the lower extremity in men is usually highly suggestive of this diagnosis. Data on gout in women, however, are limited. In women, gout is therefore often not included in the differential diagnosis of arthritis. We therefore studied the epidemiology and clinical presentation of gout in women and compared them with those of gout in men. Subsequently, the data were analysed for features that distinguish gout from arthritis of other origin in women and thus help avoid misdiagnosis.

Patients/Methods This retrospective study included all patients who were treated at the University Medical Centre of the TU Dresden with a primary discharge diagnosis of gout (ICD-10 M10.XX) between 2012 and 2018. Clinical, laboratory and radiological findings were recorded and analysed in a descriptive and multivariate approach using SPSS and R. In a second step, the data from women with gouty arthritis were compared with those without gout (monarthritis of a different origin) and checked for significance using univariate and multivariate regression analysis.

Results A total of 238 gout patients (71 women, 167 men) were included. Women in this cohort were 20 years older on average than men at the time of diagnosis and then more frequently had several comorbidities: 92% of all gout patients suffered from hypertension (men 74%), 84% had an eGFR <60 ml/min (men 52%) and 40% had previous cardiovascular events (men 14%). 90% took diuretics on a regular basis (men 47%). Almost half of the women already had overt osteoarthritis (47 vs. 30% of men). Clinically, classic MTP I arthritis occurred less frequently in women (69 vs. 84%). A comparison of women with gout confirmed by microscopic crystal detection and women with crystal-negative monarthritis showed that women with gout were older and significantly more likely suffered from hypertension or cardiovascular disease, type 2 diabetes mellitus, or obesity, or were taking diuretics. In those additionally suffering from impaired kidney function and hyperuricemia, gout was almost certainly present.

Conclusion Gout needs to be considered in the differential diagnosis of acute monarthritis in women. This is particularly true if they are past retirement age, suffer from hypertension, cardiovascular disease, type 2 diabetes mellitus or obesity and regularly take diuretics. Impaired kidney function and serum uric acid> 390 µmol / l (> 6.5 mg / dL) greatly increase the likelihood of gout.

Keywords

female - diagnosis - score - urate - gout

Publication History

Article published online:
01 December 2020

• Literatur

• 1 Kiltz U, Perez-Ruiz F, Uhlig T. et al. Prevalence and Incidence of Gout, Its Associated Comorbidities and Treatment Pattern: An Epidemiological Study from Germany. [abstract]. Arthritis Rheumatol. 2018; 70 (suppl 10): https://acrabstracts.org/abstract/the-prevalence-and-incidence-of-gout-its-associated-comorbidities-and-treatment-pattern-an-epidemiological-study-from-germany/
• 2 Annemans L, Spaepen E, Gaskin M. et al. Gout in the UK and Germany: prevalence, comorbidities and management in general practice 2000-2005. Ann Rheum Dis 2008; 67: 960-966
• 3 Schröder HE. Gicht. In Hartmann F, Philipp T. Klinik der Gegenwart. Urban & Schwarzenberg; 1993. München: 1-48
• 4 Gröbner W, Zöllner N. Hyperuricemia. Internist (Berl) 1995; 36: 1207-1221
• 5 Janssens HJ, Fransen J, van de Lisdonk EH. et al. A diagnostic rule for acute gouty arthritis in primary care without joint fluid analysis. Arch Intern Med 2010; 170: 1120-1126
• 6 Hense S, Luque Ramos A, Callhoff J. et al. [Prevalence of rheumatoid arthritis in Germany based on health insurance data : Regional differences and first results of the PROCLAIR study]. Z Rheumatol 2016; 75: 819-827
• 7 Drivelegka P, Sigurdardottir V, Svärd A. et al. Correction to: Comorbidity in gout at the time of first diagnosis: sex differences that may have implications for dosing of urate lowering therapy. Arthritis Res Ther 2018; 20: 206
• 8 Te Kampe R, Janssen M, van Durme C. et al. Sex differences in the clinical profile among patients with gout: cross-sectional analyses of an observational study. J Rheumatol 2020;
• 9 Hansildaar R, Vedder D, Baniaamam M. et al. Cardiovascular risk in inflammatory arthritis: rheumatoid arthritis and gout. Lancet Rheumatol 2020;
• 10 Vargas-Santos AB, Neogi T, da Rocha Castelar-Pinheiro G. et al. Cause-Specific Mortality in Gout: Novel findings of elevated risk of non-cardiovascular-related deaths. Arthritis Rheumatol 2019; 71: 1935-1942
• 11 Meyers OL, Monteagudo FS. A comparison of gout in men and women. A 10-year experience. S Afr Med J 1986; 70: 721-723
• 12 Kienhorst LB, Janssens HJ, Fransen J. et al. The validation of a diagnostic rule for gout without joint fluid analysis: a prospective study. Rheumatology (Oxford) 2015; 54: 609-614.
• 13 Forbess LJ, Fields TR. The broad spectrum of urate crystal deposition: unusual presentations of gouty tophi. Semin Arthritis Rheum 2012; 42: 146-154.
• 14 Suresh E. Problem based review: The patient with acute monoarthritis. Acute Med 2013; 12: 111-116
• 15 Richardson JC, Liddle J, Mallen CD. et al. “Why me? I don't fit the mould I am a freak of nature”: a qualitative study of women's experience of gout. BMC Womens Health 2015; 15: 122
• 16 Araujo EG, Manger B, Perez-Ruiz F. et al. Imaging of gout: New tools and biomarkers?. Best Pract Res Clin Rheumatol 2016; 30: 638-652
• 17 Abdellatif W, Ding J, Khorshed D. et al. Unravelling the mysteries of gout by multimodality imaging. Semin Arthritis Rheum 2020; 50: 17-23
• 18 Huppertz A, Hermann KG, Diekhoff T. et al. Systemic staging for urate crystal deposits with dual-energy CT and ultrasound in patients with suspected gout. Rheumatol Int 2014; 34: 763-71.
• 19 Petsch C, Araujo E, Hueber A. et al. Gout mimicking rheumatoid arthritis. Semin Arthritis Rheum 2017; 46: e15
• 20 Richette P, Doherty M, Pascual E. et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis 2017; 76: 29-42
• 21 Kiltz U, Alten R, Fleck M. et al. [Evidence-based recommendations for diagnostics and treatment of gouty arthritis in the specialist sector: S2e guidelines of the German Society of Rheumatology in cooperation with the AWMF]. Z Rheumatol 2017; 76: 118-124
• 22 Neogi T, Jansen TL, Dalbeth N. et al. 2015 Gout classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Ann Rheum Dis 2015; 74: 1789-1798
• 23 Bruderer S, Bodmer M, Jick SS. et al. Use of diuretics and risk of incident gout: a population-based case-control study. Arthritis Rheumatol 2014; 66: 185-196
• 24 Tausche AK, Gehrisch S, Panzner I. et al. A 3-day delay in synovial fluid crystal identification did not hinder the reliable detection of monosodium urate and calcium pyrophosphate crystals. J Clin Rheumatol 2013; 19: 241-245
• 25 Pérez-Ruiz F, Jansen T, Tausche AK. et al. Efficacy and safety of lesinurad for the treatment of hyperuricemia in gout. Drugs Context 2019; 8: 212581
• 26 Borghi C, Agabiti-Rosei E, Johnson RJ. , et al. Hyperuricaemia and gout in cardiovascular, metabolic and kidney disease. Eur J Intern Med 2020; 80: 1-11.
• 27 Toms B. Driveline sepsis presenting as gout. Cureus. 2020; 12: e7196
• 28 Prior-Español Á, García-Mira Y, Mínguez S. et al. Coexistence of septic and crystal-induced arthritis: A diagnostic challenge. A report of 25 cases. Reumatol Clin 2019; 15: e81-e85