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Suspected acute gout — SCE Rheumatology MCQ

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ModerateHyperuricaemiaSuspected acute goutSCE Rheumatology

A 57-year-old man presents with his first episode of abrupt, severe pain, erythema and swelling of the right first metatarsophalangeal joint. Symptoms began overnight 18 hours ago. He is afebrile, has no skin breach or systemic illness, and the clinical suspicion of septic arthritis is low. The effusion is too small for successful aspiration. Serum C-reactive protein is 32 mg/L, neutrophil count is 8.1 × 10⁹/L, eGFR is 68 mL/min/1.73 m² and serum urate is 330 micromol/L. His symptoms improve promptly with naproxen. Which is the most appropriate next investigation to clarify the suspected diagnosis of gout?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: A — Repeat the serum urate at least 2 weeks after the flare has settled

Explanation lettering: C = shown as A · D = shown as C · A = shown as D

The presentation is highly characteristic of podagra, but the serum urate is below the diagnostic threshold of 360 micromol/L. Serum urate may fall during an acute inflammatory flare, so this result does not exclude gout. NICE recommends repeating serum urate at least 2 weeks after the flare has settled when gout remains strongly suspected despite a value below 360 micromol/L. A is too early: a measurement taken while the flare is active or only beginning to improve may remain misleadingly low. B is a plausible alternative when aspiration cannot be performed, but imaging is reserved for situations in which the diagnosis remains uncertain after appropriate clinical and biochemical assessment; ultrasound findings are also not wholly specific. C applies the required threshold and timing and is therefore the best next investigation. D may identify urate deposition when diagnostic uncertainty persists, particularly if aspiration is impossible, but immediate escalation to dual-energy CT is unnecessary after a single classical attack with an acutely low serum urate. E does not establish the diagnosis of gout and is not routinely required to classify hyperuricaemia as overproduction or underexcretion.

Reference: Gout: diagnosis and management — Recommendations (9 June 2022) — https://www.nice.org.uk/guidance/ng219/chapter/Recommendations