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Gout — SCE Rheumatology MCQ

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EasyCrystal ArthropathyGoutSCE Rheumatology

A 55-year-old man develops rapid-onset severe pain, redness and swelling of the first metatarsophalangeal joint. During the flare, his serum urate is 310 micromol/L. Synovial-fluid microscopy demonstrates needle-shaped, negatively birefringent crystals. Which statement best interprets the serum urate result?

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Correct answer: E — It does not exclude gout during an acute flare

The correct answer is E. Serum urate may fall during an acute gout flare, so a value of 310 micromol/L does not exclude gout. NICE advises repeating a result below 360 micromol/L at least 2 weeks after the flare has settled when gout is suspected. Here, the diagnosis is established by synovial-fluid identification of needle-shaped, negatively birefringent monosodium urate crystals. The result therefore neither excludes gout nor indicates calcium pyrophosphate deposition, which produces rhomboid, positively birefringent crystals. A serum urate of 310 micromol/L is below, not above, the NICE clinical diagnostic threshold of 360 micromol/L. Serum urate concentration alone cannot demonstrate chronic tophaceous disease, which requires clinical or imaging evidence of substantial crystal deposition.

Reference: National Institute for Health and Care Excellence. Gout: diagnosis and management (NG219), recommendations 1.1.7–1.1.9 and rationale on diagnosis. 2022. https://www.nice.org.uk/guidance/ng219/chapter/Recommendations