Back to Back Issues Page
Gout Dugout.Issue #078 | gout crystals & the microscope test for gout | the best purines table
July 04, 2017

Hello and Welcome to the Summer 2017 edition of the Gout Dugout newsletter. The Gout Dugout is the 15 minutes' read from that gives you useful ideas that may help you with your gout.

In this issue we begin with the best test for gout, go on to the best purines table you can get free, and end with the progress of a very promising new gout drug.


Although the joint aspiration (aka arthrocentesis) test is the best test for gout, in fact the only real test for gout, it isn’t perfect, and may not work well. There are some snags with this test and you might run into them.

In theory, what happens is that a sample of synovial fluid (the fluid in the gouty joints) is taken from the gout attack site. An examination under an illuminated, polarised, (polarized) microscope, which is a microscope using polarising filters somewhat similar to the polarising filter you may have for your camera. It reveals whether there are MSU gout crystals or not to the trained eye.

The gout crystals are birefringent. It is this property that makes the polarizing filter able to connect with them, which makes the crystals visible. They are yellow or blue in colour (color), depending on their position in relation to the polarizing filter or polarizer. The crystals are needle shaped with sharp ends that causes the pain. You won't see them with your naked eye. If correctly identified, they confirm gout.

Antonie van Leeuwenhoek, the first person to see gout's crystals under a microscope in the 1600's, said 1,000 needle shaped uric acid crystals would not equal the width of a human hair.

If correctly identified they confirm you have gout. So what are the snags ?

In the first place your regular PCP/GP doctor won’t have the necessary polarising (polarizing) microscope, nor will every rheumatologist. But your nearest hospital should have one. So to get this test done, you may have to search around, hopefully with your Doctor’s help.

Secondly, the sample of synovial fluid taken out of your joint to be examined may not be good enough. That is there may not be enough uric acid crystals which are large enough to be certain of what they are. The operator needs experience to identify crystals correctly.

Thirdly, the person doing the test on you may not be able to get enough synovial fluid – some joints don’t have much – e.g big toe joints. A "good thing" about knee gout, is that there's plenty of synovial fluid.

Do you have gout or pseudo gout ? The operator may have to tell gout crystals from pseudo gout (CPPD) crystals. CPPD - Calcium Pyrophosphate Deposition Disease - crystals are weakly birefringent. That makes the gout ones easier to compare. Gout crystals are needle shaped but the CPPD crystals of pseudo gout are rhomboid shaped.

There are other crystals in synovial fluid but they are inconsequential.

So is it gout ? If the microscope operator correctly identifies the needle shaped gout crystals - long (around 1/8 inch ), very thin, flared along the horizontal sides, blue or yellow in colour (color), sharp pointed ends - you have gout, no question. That might save you two years or more trying to decide what you have got.

I don’t know how many readers have actually undergone the joint aspiration/arthrocentesis test for gout. But if anyone has an experience to relate, I would be very pleased to hear from you.

Take a look at Gout crystals

Rhomboid shapes

Antoni van Leeuwenhoek - here on a Rwandan (Africa) stamp


Whereas over the years, institutions, government research bodies and others, have paid for thousands of gout studies somehow an obvious one that gouty individuals would find very useful has eluded sponsorship and publication.We need a really detailed purines table which also shows the main purines’ breakdown - adenine, guanine, hypoxanthine and xanthine - of all foods and major alcoholic drinks.

Purines remain relatively unknown among general publics everywhere. And among chefs, celebrity and otherwise, too. They are not on nutrition facts panels.

If you know the four main purines in a food, and most usefully the amount of each purine in each food. And if you know that one of them, hypoxanthine, is thought to create more uric acid than the others, you would be able to refine a low purine diet somewhat further to reduce consumption of the hypoxanthine purine. The one that matters most in the creation of uric acid.

To some extent you can do this here by studying this purines table,(link below), which gives the breakdown for many foods.

The tables list a lot of Japanese and Asian foods, but there are enough Western foods to be useful to Western people too.

Thanks to the Gout Foundation of Japan for arranging the research for these useful tables a few years ago.

Free download - Japanese purines table


Regular readers know that I am encouraged about a new biologic gout drug under development – pegsiticase/SEL 212.This one, if it makes it, goes a step further than an existing biologic for gout for treating patients with advanced gout.

If it becomes a treatment one day you’d have to be an advanced gout patient to be treatable by it. But you may become an advanced chronic patient one day, so it’s worth hearing about.

It attempts to deal with many of the adverse effects of a biologic.

The excellent idea here is to marry SVP Rapamycin (anti the adverse and side effects), to pegsiticase (Uricase Peg-20 - lowers uric acid). The resulting compound is called SEL-212. Uricase PEG -20 has been around for years but until now no-one in the world of gout did anything with it.

The problem with biologics, where you get a regular infusion, not take tablets, and despite their pegylation,(i.e PEG), is their adverse reactions and side effects. But SVP modifies the immune system’s response to the arrival of gout’s MSU crystals and inhibits harmful responses to biologic treatment.

This is what a gout biologic needs, since most patients treated with them develop unwanted reactions.At the same time, pegsiticase is good at lowering uric acid.

You can see what a golden prize the developers are aiming for – a very effective gout drug that lowers serum (blood) uric acid fast (in a matter of hours), and with a big reduction, (down to near zero) and a treatment that doesn’t cause adverse reactions.

So what happened ? In mid June, Pegsiticase/SEL's developer, Selecta Biosciences, reported on its Phase 2 trial. Phase 2 trials are the trials before the last Phase 3 trials. In the report, it said 60 patients controlled their uric acid below the famous 6.0 mg/dL level. Regular dosing kept uric acid down.

Only 15% of trialists receiving SEL212 reported a flare in the first month, and this percentage fell in subsequent months. Few suffered adverse reactions, of which many were really unrelated to the treatment.

If it works successfully, this will be something the other gout biologics don't do. I've been reading about gout drug trials for years, and I can't recall any where drug under test has done so well. But pesky old gout is still at it - it wasn't 100 % perfect.

Werner Cautreels CEO of Selecta said “ First and foremost, the clinical data demonstrate SEL-212’s potential to address substantial unmet needs for patients with chronic severe gout, a debilitating disease that has been associated with both increased morbidity and mortality. We believe that a reduction of serum uric acid levels to near zero during treatment, a reduction in the incidence of flares and the convenience of safe monthly dosing with SEL-212 would prove to be a compelling treatment option."

Indeed so.

Selecta Bioscienses say they plan to begin Phase 3 trials next year, the last trials before any possible regulatory approval. Gout patients, watch this space.

More about pegsiticase/SEL here: Uricase for gout (Uricase Peg-20).

Kidney Stone Natural Treatment

If you are not a subscriber to the Gout Dugout, this free gout newsletter, you can sign up at this page - click on the link below.

Back Issues for The Gout Dugout Newsletter

Go to the home page by clicking on this link.


Use's search box, located towards the bottom of the Home Page, to find site references to any word you enter into it. It is a good way to find out where and what the site has to say about any gout topic. For example, want to know more about Krystexxa for gout? Type Krystexxa in the search box.

There are currently around 260 pages, including all the back issues of this newsletter. It works. Use it!

Next issue - Autumn/Fall 2017, end of September.

Thanks for reading and all the best of gout free health.

John Mepham BA (Econ)
Makati City

Back to Back Issues Page