What are the main differences between gout and pseudogout. How do the crystal types differ in these conditions. Which joints are typically affected by gout versus pseudogout. What causes gout and pseudogout to develop. How are these conditions diagnosed and treated.

Understanding Gout and Pseudogout: Crystalline Arthropathies

Gout and pseudogout are both classified as crystalline arthropathies – joint conditions caused by the accumulation of crystals. While they share some similarities, there are important distinctions between these two conditions in terms of their underlying causes, affected joints, and treatment approaches.

At their core, both gout and pseudogout involve the formation of crystals in joint tissues, leading to inflammation, pain, and potential joint damage over time. However, the specific types of crystals involved differ between the two conditions:

• Gout is caused by the buildup of sodium urate crystals
• Pseudogout results from calcium pyrophosphate crystal deposits

These distinct crystal compositions contribute to differences in how the conditions manifest and progress. Understanding these nuances is crucial for accurate diagnosis and effective management of gout and pseudogout.

Crystal Composition: The Foundation of Difference

The fundamental difference between gout and pseudogout lies in the composition of the crystals that form in the joints. How do these crystals differ?

• Gout crystals: Composed of sodium urate, these crystals have a distinctive needle-like shape. Under polarized light microscopy, they exhibit negative birefringence.
• Pseudogout crystals: Made of calcium pyrophosphate, these crystals have a rhomboid shape. They display positive birefringence under polarized light.

The unique properties of these crystals not only aid in diagnosis but also influence the course of each condition. Urate crystals in gout tend to cause more intense, acute attacks, while calcium pyrophosphate crystals in pseudogout may lead to more chronic, low-grade inflammation in some cases.

Joint Involvement: Patterns and Preferences

While both gout and pseudogout can affect various joints in the body, they often show distinct patterns of joint involvement. Which joints are typically affected by each condition?

Gout Joint Involvement

Gout has a strong predilection for certain joints:

• The first metatarsophalangeal joint (big toe) is affected in about 50% of initial gout attacks, a condition known as podagra
• Other commonly affected joints include the ankles, knees, and joints in the hands and wrists
• Gout attacks typically affect a single joint, especially in early stages of the disease

Pseudogout Joint Involvement

Pseudogout shows a somewhat different pattern:

• The knee is the most common site for initial pseudogout attacks
• Wrists, ankles, and other large joints are also frequently affected
• Pseudogout often involves multiple joints simultaneously, with 1-4 joints commonly affected during an attack

Understanding these patterns can help healthcare providers differentiate between gout and pseudogout, especially in cases where joint fluid analysis is not immediately available.

Demographic Differences: Who is at Risk?

The risk factors and typical patient profiles for gout and pseudogout differ in several key aspects. Who is most likely to develop each condition?

Gout Demographics

• More common in middle-aged and older men
• Male-to-female ratio is approximately 3:1 to 4:1
• Risk increases with age, but onset is often earlier than pseudogout
• Certain ethnic groups, such as Pacific Islanders, have higher rates of gout

Pseudogout Demographics

• Typically affects older adults, with prevalence increasing sharply after age 60
• More evenly distributed between men and women
• Rare in individuals under 60 years old

These demographic differences can provide valuable clues when considering a diagnosis, although it’s important to note that exceptions can occur, and neither condition is exclusive to any particular group.

Causes and Risk Factors: Unraveling the Origins

While both gout and pseudogout involve crystal formation in joints, the underlying causes and risk factors for each condition are distinct. What leads to the development of gout versus pseudogout?

Causes of Gout

Gout is primarily caused by elevated levels of uric acid in the blood (hyperuricemia). Factors contributing to gout include:

• Dietary choices: High intake of purine-rich foods (e.g., red meat, organ meats, certain seafoods)
• Alcohol consumption: Particularly beer and spirits
• Obesity
• Certain medications (e.g., diuretics)
• Genetic factors affecting uric acid metabolism
• Medical conditions like hypertension, diabetes, and kidney disease

Causes of Pseudogout

The exact cause of pseudogout is less well understood, but several factors have been identified:

• Age-related changes in cartilage
• Genetic predisposition
• Metabolic disorders (e.g., hemochromatosis, hyperparathyroidism)
• Joint trauma or surgery
• Certain mineral imbalances (e.g., excess iron or magnesium)

Unlike gout, pseudogout is not directly linked to dietary factors or alcohol consumption. This distinction is important for both prevention strategies and patient education.

Diagnostic Approaches: Identifying the Culprit

Accurate diagnosis is crucial for effective management of gout and pseudogout. How are these conditions diagnosed and differentiated?

Joint Fluid Analysis

The gold standard for diagnosis of both conditions is joint fluid analysis:

• A sample of synovial fluid is drawn from the affected joint
• The fluid is examined under a polarizing microscope
• Gout crystals appear as needle-shaped and negatively birefringent
• Pseudogout crystals are rhomboid-shaped and positively birefringent

Imaging Studies

X-rays and other imaging techniques can provide additional diagnostic information:

• Gout: X-rays may show soft tissue swelling in early stages, with erosions and tophi (crystal deposits) in advanced cases
• Pseudogout: Calcifications in joint cartilage (chondrocalcinosis) are often visible on X-rays
• Advanced imaging like dual-energy CT can detect urate crystal deposits in gout

Blood Tests

While not definitive, blood tests can support diagnosis:

• Elevated serum uric acid levels are common in gout but not specific
• Normal uric acid levels are typical in pseudogout
• Inflammatory markers (e.g., ESR, CRP) may be elevated in both conditions during acute attacks

It’s important to note that while these diagnostic approaches are helpful, clinical presentation and expert evaluation remain crucial in distinguishing between gout and pseudogout, especially in cases where crystal analysis is not immediately available.

Treatment Strategies: Tailoring Approaches to Each Condition

While gout and pseudogout share some similarities in their acute management, their long-term treatment strategies differ significantly. How are these conditions treated, and what are the key differences in their management?

Acute Attack Management

For both gout and pseudogout, the immediate goal is to reduce pain and inflammation:

• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Colchicine
• Corticosteroids (oral or intra-articular injections)
• Rest and ice application to affected joints

Long-term Management of Gout

Gout treatment focuses on lowering uric acid levels and preventing future attacks:

• Urate-lowering therapy (e.g., allopurinol, febuxostat)
• Dietary modifications to reduce purine intake
• Weight management
• Limiting alcohol consumption, especially beer and spirits
• Addressing underlying conditions (e.g., hypertension, kidney disease)

Long-term Management of Pseudogout

Pseudogout management is more focused on symptom control and preventing joint damage:

• Low-dose colchicine for prophylaxis in some cases
• NSAIDs or other anti-inflammatory medications for chronic pain
• Physical therapy to maintain joint function
• Treatment of underlying metabolic disorders if present

The distinct approaches to long-term management reflect the different underlying mechanisms of gout and pseudogout. While urate-lowering therapy is a cornerstone of gout management, there is no equivalent treatment to directly address calcium pyrophosphate crystal formation in pseudogout.

Prognosis and Complications: Long-term Outlook

Understanding the potential long-term consequences of gout and pseudogout is crucial for patients and healthcare providers. What are the typical prognoses for these conditions, and what complications can arise?

Gout Prognosis and Complications

With proper management, the outlook for gout is generally positive:

• Effective urate-lowering therapy can prevent future attacks and joint damage
• Untreated or poorly managed gout can lead to:
• Chronic joint pain and stiffness
• Joint deformity and reduced mobility
• Tophi formation (visible urate crystal deposits under the skin)
• Kidney stones and potential kidney damage
• Gout is associated with an increased risk of cardiovascular disease

Pseudogout Prognosis and Complications

The long-term outlook for pseudogout is more variable:

• Some patients experience only occasional acute attacks with minimal long-term impact
• Others may develop a chronic form of arthritis similar to osteoarthritis
• Potential complications include:
• Progressive joint damage and deformity
• Reduced joint function and mobility
• Chronic pain
• Unlike gout, pseudogout is not directly associated with systemic complications like cardiovascular disease

For both conditions, early diagnosis and appropriate management are key to minimizing long-term joint damage and maintaining quality of life. Regular follow-up with healthcare providers is essential to adjust treatment strategies as needed and monitor for potential complications.

Prevention Strategies: Minimizing Future Attacks

While gout and pseudogout cannot always be prevented entirely, there are strategies to reduce the frequency and severity of attacks. How can individuals at risk for these conditions minimize their chances of developing symptoms?

Gout Prevention

Preventing gout attacks focuses largely on lifestyle modifications and maintaining healthy uric acid levels:

• Dietary changes:
• Limit intake of purine-rich foods (e.g., red meat, organ meats, certain seafoods)
• Increase consumption of low-fat dairy products, which may have a protective effect
• Stay hydrated to help flush uric acid from the body
• Alcohol moderation:
• Limit beer and spirits consumption
• Wine in moderation appears to have less impact on gout risk
• Weight management: Maintaining a healthy weight can help reduce uric acid levels
• Regular exercise: Physical activity can help control weight and improve overall health
• Medication management: Work with healthcare providers to adjust medications that may contribute to hyperuricemia
• Urate-lowering therapy: For individuals with recurrent gout, long-term use of urate-lowering medications can prevent future attacks

Pseudogout Prevention

Preventing pseudogout attacks can be more challenging, as the underlying causes are less well understood. However, some strategies may help:

• Joint protection: Avoid excessive stress on joints prone to pseudogout attacks
• Stay active: Regular, low-impact exercise can help maintain joint health
• Manage underlying conditions: Treat any associated metabolic disorders or mineral imbalances
• Consider prophylactic medication: In some cases, low-dose colchicine or NSAIDs may be prescribed to prevent attacks
• Maintain a healthy lifestyle: While not directly linked to pseudogout, overall health can impact joint function and inflammation

It’s important to note that prevention strategies should be tailored to each individual’s specific circumstances and risk factors. Regular consultation with healthcare providers can help develop and adjust prevention plans as needed.

By understanding the key differences between gout and pseudogout – from their underlying crystal composition to their typical patterns of joint involvement and treatment approaches – patients and healthcare providers can work together to effectively manage these conditions. While both can cause significant discomfort and potential long-term joint damage, proper diagnosis, treatment, and prevention strategies can greatly improve outcomes and quality of life for those affected by these crystalline arthropathies.

What is the Difference Between Gout and Pseudogout?

Gout and pseudogout sound very similar. What do they have in common?
 
Gout and pseudogout are both conditions in which substances that should be dissolved in the blood or body fluids becomes a solid chalky white material in tissues. Both of these conditions have the crystals that can build up in joints resulting in pain, swelling and possibly even joint damage. White blood cells called macrophages try to digest the crystals which causes them to release toxic chemicals causing inflammation. Conditions like these are called crystalline arthropathies, because they are joint problems (arthropathies) caused by crystals (crystalline). Normal joints do not have crystals in them. 
 
Does having pseudogout mean “kind of” having gout?
 
Gout and pseudogout, while both joint problems caused by crystals, are caused by different kinds of crystals.  Gout is caused by sodium urate crystals and pseudogout is caused by calcium pyrophosphate crystals.  
 
Who gets gout and pseudogout?  What are the causes?  Are the same joints affected?
 
Gout is most common in middle-aged men and usually starts in the large toe. This is called podagra.  The knee is the most common place for pseudogout to start.  Pseudogout tends to occur more evenly in men and women and usually occurs in older people.  Gout attacks can sometimes be caused by eating lots of red meat, particularly organ meats that are high in purines. Drinking certain types of alcohol, such as beer and distilled liquor may increase attacks. Wine does not seem to cause gout.  Pseudogout is not related to diet.  In both conditions, joints in the hand and wrist can be involved. 
 
How are gout and pseudogout diagnosed? 
 
The best way for your doctor to make the diagnosis is to draw fluid from an affected joint and look at it under a special microscope.  Gout and pseudogout crystals can be seen with the microscope and they look different when viewed in a special polarized light under a microscope. Gout crystals are shaped like a needle and are negatively birefringent. Pseudogout crystals are rhomboid shaped and positively birefingent. X-rays can also be helpful as they show different changes.  Gout eats away at the bones and joints of the hand and wrist. There may be many small cystic erosions in the bones at the joint surfaces.  Pseudogout may be seen on x-ray due to the calcium crystals depositing in the soft tissues around the joints.  Blood levels of urate are often elevated in gout but are normal in pseudogout. 
 
What else can be confused with gout and pseudogout? 
 
Fractures, infection, osteoarthritis and other inflammatory problems such as rheumatoid arthritis can be confused with gout and pseudogout.  Your hand surgeon can help tell these conditions apart and ensure you get the right treatment. 
 
How are gout and pseudogout treated?  Are they treated the same? 
 
Treatment differs and that is why getting the right diagnosis is important. In both cases, steroid injections (cortisone shots), anti-inflammatory medications and colchicine may be useful.  For gout, your medical doctor may prescribe a mediation that decreases urate and may also recommend diet changes to keep gout from coming back. 
 
I think I have one of these problems!  How can I find a hand surgeon to help me? 
 
Please check out the Find a Hand Surgeon tool from the American Society for Surgery of the Hand to find a hand surgeon near you.
 

Ryan Zimmerman, M.D. is a Hand, Shoulder and Elbow Surgeon in Baltimore, Maryland.  He is a member of Greater Chesapeake Hand to Shoulder and an Attending Surgeon at the Curtis National Hand Center.
 

4 Ways Gout and Pseudogout Are Different

Both gout and pseudogout cause sudden joint pain, swelling, and redness, making the two diseases difficult to tell apart. Understanding what makes each condition unique can help when diagnosing, treating, and preventing flare-ups, ultimately minimizing permanent joint damage.

Pseudogout is also known as acute calcium pyrophosphate crystal arthritis (acute CPP crystal arthritis). This page describes four ways gout and pseudogout are different.

Half of all gout attacks affect the joint in the big toe. Learn more: Gout Symptoms

1. Joints affected

Gout attacks typically affect only one joint.

¹
Ragab G, Elshahaly M, Bardin T. Gout: An old disease in new perspective–A review. J Adv Res. 2017. Sep 1;8(5):495-511. PMCID: PMC5512152 DOI: 10.1016/j.jare.2017.04.008
In contrast, pseudogout attacks commonly affect between 1 and 4 joints.

²
Slobodonick A, Toprover M, Pillinger M. Crystal Arthritis. In: Efthimiou P, ed. Absolute Rheumatology Review. Springer Nature Switzerland AG; 2020; chap 15. Accessed September 15, 2020. https://doi.org/10.1007/978-3-030-23022-7_15
In addition, the locations of the flare-ups tend to differ:

• Gout most commonly affects the big toe, instep, heel, ankle, and/or knee.

  ³
  Sidari A, Hill E. Diagnosis and Treatment of Gout and Pseudogout for Everyday Practice. Prim Care. 2018;45(2):213-236. doi:10.1016/j.pop.2018.02.004
  About 50% of first-time gout attacks in men involve a big toe joint.

  ²
  Slobodonick A, Toprover M, Pillinger M. Crystal Arthritis. In: Efthimiou P, ed. Absolute Rheumatology Review. Springer Nature Switzerland AG; 2020; chap 15. Accessed September 15, 2020. https://doi.org/10.1007/978-3-030-23022-7_15
  In women, who are significantly less likely to develop gout, an attack is most likely to involve a knee.

  ²
  Slobodonick A, Toprover M, Pillinger M. Crystal Arthritis. In: Efthimiou P, ed. Absolute Rheumatology Review. Springer Nature Switzerland AG; 2020; chap 15. Accessed September 15, 2020. https://doi.org/10.1007/978-3-030-23022-7_15

• Pseudogout is most likely to affect the knee, wrist, and/or large knuckles of the hand (metacarpophalangeal joints). It may also involve the hip, shoulder, and/or spine.

  ²
  Slobodonick A, Toprover M, Pillinger M. Crystal Arthritis. In: Efthimiou P, ed. Absolute Rheumatology Review. Springer Nature Switzerland AG; 2020; chap 15. Accessed September 15, 2020. https://doi.org/10.1007/978-3-030-23022-7_15
  ^{,
  4}
  Genetic and Rare Diseases Information Center, National Institute for Advancing Translational Sciences. Chondrocalcinosis 2. Last updated January 12, 2018. Accessed August 4, 2020. https://rarediseases.info.nih.gov/diseases/1292/chondrocalcinosis-2
  Unlike gout, pseudogout rarely affects the big toe.

  ²
  Slobodonick A, Toprover M, Pillinger M. Crystal Arthritis. In: Efthimiou P, ed. Absolute Rheumatology Review. Springer Nature Switzerland AG; 2020; chap 15. Accessed September 15, 2020. https://doi.org/10.1007/978-3-030-23022-7_15

While certain joints are more likely to be affected, both gout and pseudogout can affect any joint in the body.

See Gout Symptoms and Pseudogout Symptoms

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2. Causes

Gout and pseudogout are both caused by microscopic crystals that collect in a joint and trigger inflammation, which causes pain. The types of crystals are different:

• Gout is caused by monosodium urate crystals, often referred to as uric acid crystals.
• Pseudogout is caused by calcium pyrophosphate dihydrate crystals, often referred to as calcium pyrophosphate crystals (CPP crystals).

Not everyone who has urate crystals or CPP crystals in a joint will experience inflammation and pain. Researchers do not fully understand why these microscopic crystals lead to painful flare-ups in some people but not others.

See Gout Causes and Risk Factors and Pseudogout Causes

3. Severity, timing, and duration of pain

While gout and pseudogout can cause notable joint pain without warning, the severity of pain, when it appears, and how long it lasts may differ:

Even though gout and pseudogout flare-ups will go away on their own, treatment is encouraged. Joint damage is more likely to occur without treatment.

See Pseudogout Treatment and Gout Treatment

4. Tendon involvement

People with pseudogout are more likely to have a build-up of calcium deposits in the tendons of the affected joint.

⁵
Miksanek J, Rosenthal AK. Imaging of calcium pyrophosphate deposition disease. Curr Rheumatol Rep. 2015;17(3):20. PMID: 25761927 doi: 10.1007/s11926-015-0496-1
These deposits are called calcifications. Tendon calcifications can occur because the crystals that cause pseudogout—calcium pyrophosphate dihydrate crystals—contain calcium.

Calcifications can be seen on x-rays as thin lines that run in the same direction as the tendon. Tendons that have undergone calcification may be inflamed and painful.

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People with gout can have deposits of uric acid crystals in tendons. These deposits can be detected by certain types of imaging tests, such as musculoskeletal ultrasound.

⁶
Pascart T, Lioté F. Gout: state of the art after a decade of developments. Rheumatology. 2019; Jan 1;58(1):27-44. PMID: 29547895 DOI: 10.1093/rheumatology/key002
Uric acid crystal deposits or too much uric acid in a tendon may lead to inflammation and/or damage to the tendon (tendinopathy),

⁷
Andia I, Abate M. Hyperuricemia in Tendons. Adv Exp Med Biol. 2016;920:123-32. doi: 10.1007/978-3-319-33943-6_11. PMID: 27535254 DOI: 10.1007/978-3-319-33943-6_11
^,
8
Ray K. Crystal arthritis: Tendon damage in gout–a role for MSU crystals? Nat Rev Rheumatol. 2014 Jun;10(6):321. doi: 10.1038/nrrheum.2014.65. Epub 2014 Apr 22. PMID: 24752181 DOI: 10.1038/nrrheum.2014.65
which can be painful.

Both gout and pseudogout are treatable conditions. People who suspect they have gout or pseudogout are advised to seek a definitive diagnosis confirmed by medical imaging and lab tests.

Learn more

How to Prevent the Next Gout Attack

Being Overweight Linked to Gout Risk

Dr. Nadine Mbuyi is a board-certified rheumatologist and internal medicine physician. She is also an assistant professor at the George Washington University School of Medicine. She specializes in diagnosing and treating rheumatic diseases, with a particular interest in gout, CPPD disease (pseudogout), lupus, rheumatoid arthritis, osteoarthritis, and seronegative spondyloarthropathies.

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How not to confuse real gout with another disease

Pseudogout

is a disease that mimics the symptoms of gout, but they are caused by a different cause.

Pseudogout is characterized by rare but rather acute attacks of rheumatoid arthritis and is characterized by severe pain.

Causes of pseudogout

There are several reasons for the development of pseudogout, but it is not always possible to determine the exact etiological factor. The main risk factors for the development of the disease are advanced age and joint injuries.

The most common causes of pseudogout are:

— hereditary predisposition. Patients found with pseudogout often have a mutation in the ANKH gene (locus 5p15.2), which encodes a protein that transports intracellular inorganic pyrophosphate;

– an excessive increase in the level of calcium in the blood, which is the result of too high levels of parathyroid hormone in the blood.

– elevated levels of iron in tissues.

– low levels of magnesium in the blood.

Any joint dysfunction is a reason to seek medical help.

– attacks of severe joint pain;

– swelling or redness of individual joints;

– chronic pain in the joints.

– lack of mobility in the joints.

A rheumatologist deals with the treatment of joint diseases. Only a doctor can make the correct diagnosis and choose the appropriate treatment.

Symptoms

Pseudogout manifests itself with symptoms that are very similar to those of classic gout:

– the appearance of swelling in the affected joints. Sometimes visually noticeable edematous bumps form on the joint.

– fever in the affected area of ​​the body. The skin over the joint becomes red and hot to the touch.

– severe pain. The pain can be sharp and sharp, or sometimes dull and constant.

In some cases, pseudogout may present with only slight soreness for a long time.

For a correct diagnosis, it is necessary to contact a rheumatologist who will conduct a detailed analysis of the patient’s condition and prescribe the appropriate treatment.

Gout attack

Gout attack is a disease that causes severe pain and swelling of the joints, usually the big toe. It is caused by high levels of uric acid in the blood, which forms crystals in the joints.

A rheumatologist also treats a gout attack. Using a well-chosen treatment regimen, which includes the use of anti-inflammatory and pain medications, as well as a special diet that excludes foods containing a large amount of uric acid, good positive results can be achieved.

Pseudogout and a gout attack without observation and proper treatment can lead to destruction of the joints, so it is necessary to contact a rheumatologist in a timely manner and follow the recommendations for treatment and prevention. Trying to deal with the problem on your own can lead to serious consequences.

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Test material
Articular (synovial) fluid

Violation of the exchange of purine bases in the body with gout leads to an increase in the content of uric acid in the blood and synovial fluid. An acute attack of gouty arthritis is accompanied by crystallization of salts with the formation of sodium monourate crystals. Direct detection of crystals is possible when examining the joint fluid. Thin needle-shaped crystals of sodium monourate can be located intra- and extracellularly. When examined in polarized light, they can be identified due to their characteristic negative birefringence.

Another form of microcrystalline arthritis is pseudogout, which is accompanied by the formation of calcium pyrophosphate crystals, which are thought to result from changes in pyrophosphate metabolism in the articular cartilage. Unlike sodium monourate, calcium pyrophosphate crystals in pyrophosphate arthropathy are thicker and shorter, and also have positive birefringence.

Preparation

No special preparation required. Biomaterial for research is obtained by puncture of the joint or arthroscopy.

Indications for prescription

• differential diagnosis of arthritis;
• diagnosis of gout;
• diagnosis of pyrophosphate arthropathy (pseudogout).

Interpretation of results

Interpretation of test results contains information for the attending physician and is not a diagnosis.