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Saturnine Gout, Redux: A Review

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Abstract

Illicitly distilled beverages (colloquially referred to as moonshine) account for approximately one third of alcohol consumption worldwide. Moonshine is often produced in makeshift distilling units composed of old, repurposed parts, whose component elements can leach into the distillate. Consequently, the resultant beverages may inadvertently contain harmful toxins, one of which is the metal lead. One manifestation of chronic lead toxicity—from moonshine or other forms of chronic lead poisoning—is the rheumatologic entity known as saturnine gout. With the increasing prevalence of gout over the past few decades, physicians should be aware of the association of moonshine consumption or lead toxicity with gouty arthritis. In this article, we present an overview of saturnine gout, beginning with a discussion of lead poisoning in antiquity and tracing its path to modern times. The contribution of lead to human disease and the clinical features of saturnine gout are outlined. After describing the role of lead in renal insufficiency and purine metabolism, we conclude with a discussion of specific strategies to manage this clinically important form of secondary gout.

Section snippets

Historical Perspective on the “Moonshine Malady”

The earliest historical records of lead poisoning can be traced back to antiquity. Hernberg4 notes that lead-based compounds may have been used in ancient Egypt to commit murder.4 Unknowingly, Hippocrates, in his Epidemics, may have described the first case of lead toxicity, also known as plumbism: “The man from the mines; right hypochondrium strained; enlarged spleen; stomach tense…the illness went to the left knee, recurrence; he was completely examined.”5 (Plumbism, from the Latin plumbum,

Lead Toxicology and Contribution to Disease

In addition to moonshine, lead exposure worldwide can be attributed to 6 groups of products, including ceramic glazes, solder, gasoline additives, certain paint products, drinking water systems, and natural remedies.19, 20 Although moonshine consumption adds the risk of alcohol to that of lead, the promotion of gout through lead exposure and toxicity is not likely to differ whether the source is moonshine or other products.

In adults, non-moonshine lead poisoning is usually a result of

Saturnine Gout: Characteristic Features and Clinical Manifestations

In his 1886 description of saturnine gout, Lorimer25 noted certain unique characteristics in patients with lead-associated gouty arthritis compared with patients with gout without plumbism, including signs of lead toxicity, such as anemia and Burton's lines (a bluish line on the gums when lead reacts with sulfur compounds produced by bacteria), and a predilection for certain joints. In Halla and Ball's review,14 the knee was the most commonly affected joint in saturnine gout (83%) (in contrast

Mechanisms of Saturnine Gout: Role of Lead in Renal Insufficiency, Purine Metabolism, and Urate Overproduction

Our understanding of the relationships among chronic lead poisoning, renal disease, and hyperuricemia has advanced considerably over the past 100 years. Hyperuricemia is a consequence of systemic overproduction of uric acid, renal underexcretion of urate, or a combination of both. Much of the literature on lead nephropathy and urate handling implicates lead as contributing both to intrinsic kidney disease and to underexcretion of urate (Table 3), whereas a smaller body of research proposes a

Conclusions

Saturnine gout as a manifestation of lead poisoning originated in antiquity and underwent a resurgence in the 20th century, especially within rural areas of the southeastern and midwestern United States. Today, moonshiners can be found throughout the entire United States. Over the last 2 decades, the emergence of a growing number of homebrewers and their artisanal alcohol beverages has brought with it a renewed concern for lead toxicity.44 Clinicians caring for patients with gout should bear in

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    Funding: Dr Pillinger is the recipient of an investigator-initiated grant from URL Pharma/Takeda to study the effects of colchicine on cardiac disease in patients with gout.

    Conflict of Interest: None.

    Authorship: Both authors had access to the data and played a role in writing this manuscript.

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