Gout and fever

Letter to the Editor

DEAR EDITOR: The rheumatology clinic article When it isn’t gout: potential diagnostic traps, by Dr Neil McGill (Medicine Today, April 2011, pages 78 to 81), asserted that gout is not typically associated with a fever, thus helping differentiate it from septic arthritis. However, the article Beating gout: satisfaction for patient and doctor, by Professor Kevin Pile (Medicine Today, July 2011, pages 18 to 28), states that it does. Please could you clarify? GREG KURIATA MB BS, FRACGP General Practitioner, St Kilda, Vic.

REPLY 1: I am not aware of any quality study that has assessed the frequency of fever in acute gout. Expert consensus based on thorough literature reviews has not included fever as a feature of monoarticular gout.[1,2] My experience is that fever is frequent in polyarticular gout and that it may occur but is not frequent in monoarticular gout. Missing septic arthritis has serious consequences. Although it would be ideal if all acutely inflamed joints were aspirated to allow synovial fluid culture and examination for crystals, the reality is that only a small percentage are. Any clue that suggests infection is moderately likely should be highlighted and prompt the clinician to arrange joint aspiration (before considering the use of antibiotics). Fever is one such clue. NEIL McGILL MB BS(Hons), BSc(Med), FRACP Rheumatologist, Institute of Rheumatology and Orthopaedics, Royal Prince Alfred Hospital, Sydney, and Clinical Senior Lecturer, Department of Medicine, University of Sydney, NSW. References 1. Zhang W, Doherty M, Pascual E, et al. EULAR evidence based recommendations for gout. Part 1. Diagnosis. Report of a task force of the standing committee for international clinical studies including therapeutics (ESCISIT). Ann Rheum Dis 2006; 65: 1301-1311. 2. Taylor WJ, Shewchuk R, Saag KG, et al. Toward a valid definition of gout flare: results of consensus exercises using Delphi methodology and cognitive mapping. Arthritis Care Res 2009; 61: 535-543.

REPLY 2: The distinction between gout and septic arthritis can be very difficult and because of the potentially devastating consequences of septic arthritis it is always important to consider this diagnosis and undertake investigations to exclude sepsis. Although most patients with septic arthritis are febrile, not all are (for example, those with diabetes, the elderly and those who are immunosuppressed). Gout is not always associated with fever but frequently is, and often patients are treated and investigated as having septic arthritis, which leads to the ultimate diagnosis. Fever is partly induced by interleukin-6 and this is effectively elevated in both gout and sepsis. Interestingly, a Google search of gout and fever leads to several patient forums where patients with gout discuss their fevers. KEVIN PILE MB BCh, MD, FRACP Staff Specialist - Rheumatology, Department of Medicine, Campbelltown Hospital, and Conjoint Professor of Medicine, University of Western Sydney, Sydney, NSW.