Gout is the most common inflammatory arthritis and a global health problem. In addition to joint involvement, urate crystals induce chronic inflammation, leading to increased cardiovascular risk in gout. Thus, cardiovascular disease is the leading cause of death in gout and numerous studies have revealed an increase in cardiovascular-related mortality in these patients. However, despite the efficacy of urate-lowering therapies, such as allopurinol and febuxostat, suboptimal management of gout and poor adherence continue to make it difficult to achieve better outcomes. Treat-to-target strategy may help change this, as in other diseases such as rheumatoid arthritis. Nevertheless, even with a well-defined clinical target (absence of flares and tophi disappearance), the numerical target [serum uric acid (SUA) < 5 mg/dL or < 6 mg/dL] still varies depending on current guidelines and consensus documents. Recently, several trials [Long-Term Cardiovascular Safety of Febuxostat Compared with Allopurinol in Patients with Gout (FAST), REasons for Geographic And Racial Differences in Stroke (REGARDS)] have shown better cardiovascular outcomes in those patients who achieve SUA levels < 5 mg/dL. Likewise, some observational studies, mostly based on imaging tests such as ultrasound and dual-energy computed tomography, have found better results in the magnitude and speed of reduction of urate joint deposition when SUA < 5 mg/dL is achieved. Based on an analysis of the available evidence, SUA < 5 mg/dL is postulated as a more ambitious target within the treat-to-target approach for the management of gout to achieve better joint and cardiovascular outcomes in patients with cardiovascular risk or severe disease.

Gout often presents as acute arthritis but may also present with chronic joint inflammation. For the diagnosis of an acute gout attack with its typical symptoms, the differentiation towards a bacterial joint infection is critical and mandatory. The detection of intracellular uric acid crystals in the synovial fluid of affected joints is important for the initial diagnosis of gout. In the case of a chronic course with polyarticular joint involvement, the differentiation from other inflammatory rheumatic diseases such as rheumatoid arthritis (RA) can be challenging. The case presented here is of interest because the patient initially had characteristic clinical symptoms of tophaceous gout including a typical medical history—even though rheumatoid factor and anti-citrullinated protein antibodies (anti-CCP) were positive. The course of the disease and the critical evaluation of all findings also, and most interestingly, including histological results finally suggested a main diagnosis of RA.