Fig. 17.1
Polyarticular tophaceous gout. (a) Palmar view. (b) Dorsal view
Frequency of polyarticular involvement in the elderly is probably the result of multiple factors.
Chronic hyperuricemia may be induced by cardiovascular and renal diseases, as well as continuous treatment with low doses of aspirin and diuretics.
The clinical course with low intensity of the inflammatory component may cause difficulties in distinguishing between rheumatoid arthritis and polyarticular gout.
Elderly women exhibited increased incidence of gout particularly when they developed gouty arthritis in advanced age (Table 17.1). In up to 85 % of women, gouty arthritis was diagnosed after menopause. Puig et al. [8] and Park et al. [9] described in 75 % of Korean women the first symptomatic episode of gout after the onset of the menopause. On the other hand, the group of women who developed gout prior to menopause usually had renal insufficiency or were taking cyclosporin after renal transplantation. Female patients in this group were on average by 7–10 years older than men, with a shorter duration of this disorder [8, 10].
Table 17.1
Clinical symptoms of gout: typical gout vs late-onset gout
Characteristics | Typical gout | Late-onset gout |
|---|---|---|
Age at the onset of the disease | The highest incidence in the middle of fourth age decade | Older than 65 years |
Gender distribution | Men > women | Men = women |
Manifestations | Acute monoarthritis Lower limb (podagra 60 %) | Often polyarticular onset; more frequent involvement of upper limb |
Tophi | After multi-year history of attacks | More frequent involvement of fingers; may occur in the early stage without a history of previous attacks |
Associated characteristics | Elbows > fingers Obesity Hyperlipidemia Hypertension Intensive alcohol consumption | Possibility of frequent involvement of fingers Renal insufficiency Use of diuretics mainly in women Occasional alcohol consumption |
Studies published by MacFarlane and Dieppe [3], Fam et al. [11], and Lally et al. [12] have shown that in 50–60 % of women, gout developed after the age of 60; at the age over 80, gouty arthritis was found only in women.
17.2 Clinical Features of Involvement of Small Joints
In recent years, arthritis of small joints of the fingers has been more frequently noted in conjunction with gout in the elderly patients. Osteoarthritis of distal and proximal interphalangeal joints is a common feature in elderly patients, women in particular.
A typical feature is inflammatory exacerbation caused by basic hydroxyapatite crystals or other factors. In 1983, Simkin et al. suggested a potential share of gout in the inflammatory process in DIP during osteoarthritis. In a group of five patients (four women and one man at the age of 67–77 years), acute inflammation attacks were observed in joints affected by osteoarthritis, with the presence of sodium urate crystals in the involved joints.
Medical history of most patients showed a previous gouty attack. The affected joints and other sites exhibited the presence of gouty tophi. Gradually also other studies have confirmed involvement of small joints of the hand in elderly patients with gout, mainly in women. Ter Borg and Rasker [1] have pointed out the fact that elderly patients with late-onset gout had initial symptoms of the disease in fingers of hands, with the incidence in 25 % of women and their absence in men. Another study [8] has demonstrated that of all women who had gouty arthritis of upper limbs, small joints of hands are affected in about 30 % of cases.
In other studies Fam et al. [13] and Lally et al. [12] demonstrated in large groups of patients involvement of PIP and DIP joints in late-onset gouty arthritis; the mean age of women was 70 years, but involvement of DIP joints was more frequent than that of PIP joints. It should be noted that typical erosive changes in erosive osteoarthritis were sometimes hard to distinguish radiologically, but the presence of density associated with sodium urate crystal deposition in soft tissues, large intra-articular and non-marginal erosion, and osteolysis supported the diagnosis of gouty arthritis (Figs. 17.2 and 17.3). In patients with IP joint involvement and gouty arthritis, high frequency of use of diuretics was observed.
Fig. 17.2
Hands. (a) Sharply contoured multiple large defects in the finger skeleton of both hands, slightly deformed edges of articular surfaces with the presence of minor cystoid subchondral defects in MCP joints and both wrists; (b) multiple asymmetrical widening of the shadow of soft tissues in both hands and forearms, multiple round well-defined hyperlucencies of the skeleton, partially also with interrupted contours, with maximum in MCP5 on the right, PIP3 and DIP2 on the left
Fig. 17.3
Feet. Minor skeletal lesions, predominantly marginal in the form of usurations, but also pseudocystic hyperlucencies, with maximum in the left great toe joints and in DIP5 bilaterally
17.3 Early Atypical Tophaceous Gout
Initial development of tophi at atypical sites was described in elderly patients with gouty arthritis, women in particular. The incidence of tophi is higher in women (44 %) as compared to men (8 %) despite a shorter duration of the disease and less attacks. MacFarlene and Dieppe [3] found in a group of elderly women three patients who had tophi in fingers without a previous gouty attack. This tendency to tophi development without previous gouty attacks was confirmed also by other authors. In four elderly women, the incidence of tophi was described at an atypical site – in the finger pads [14]. These unusual findings occurred also in a larger group of elderly women [15]. Puig et al. [8] found in 27 % of women, mostly after menopause, tophi that were in 90 % of cases located in fingers and none above the elbow. Ter Bork and Rasker [1] analyzed the incidence of tophi in a group of elderly patients including 22 women and 18 men with gout and found no difference in the incidence of tophi in fingers between women and men. The relation between gender and the incidence of tophi in finger pads was not confirmed by Holland et al., either [16]. The cause of predisposition to atypical incidence of tophi in elderly patients is unknown.
17.4 Incidence of Gouty Arthritis in Diuretic Treatment
A high association between diuretic treatment and renal insufficiency was observed in elderly patients with gout. Use of diuretics was confirmed in 75 % of patients with late-onset gout, mainly in women (95–100 % of female patients).
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