Septic Arthritis Complicating a Gout Flare: Report of Two Cases and Review of the Literature

OBJECTIVE: To highlight potential pitfalls in diagnosis and management of patients with concomitant gout and septic arthritis. METHODS: Presentation of two patients with concomitant gout and septic arthritis, the latter caused by Streptococcus agalactiae and Staphylococcus aureus, in one patient each. We also reviewed the English language literature on PubMed for similar cases. RESULTS: Data on concurrent gout and septic arthritis is limited. Three case series of 14, 25, and 30 patients each where identified. The coexistence of septic arthritis and gout is an infrequent condition. Clinical appearance of the two diseases may be very similar and the presence of monosodium urate (MSU) crystals per se cannot exclude infection. On the other hand, patients with chronic tophaceous gout are prone to infection of MSU tophi and the development of biofilms on the latter may render the eradication of microbes particularly difficult. Vice versa, persistent activation of the immune system fuelled by the infection, together with prolonged hospitalisation and immobilisation, may increase the risk for a gout flare, thus initiating a vicious cycle. CONCLUSION: In patients with gout, a high index of suspicion for infection is needed by treating physicians, because septic arthritis is a medical emergency which can lead to rapid joint destruction.