Atypical Gout Presentation: A Case Report

Background: Gout is a common inflammatory arthritis caused by monosodium urate crystal deposition and classically presents as acute monoarthritis of the first metatarsophalangeal joint. However, atypical presentations involving unusual joint distributions, normouricemia, and misleading imaging findings can pose significant diagnostic challenges and lead to delayed or inappropriate management. Case Presentation: We report the case of a 54-year-old male with no significant comorbidities who presented with recurrent episodes of severe lateral foot pain over 18 months. Imaging revealed recurrent stress fractures involving the third and fourth metatarsals, while inflammatory markers and serum uric acid levels remained within normal limits during acute episodes. Despite orthopedic recommendations for prolonged immobilization and surgical stabilization, the patient experienced complete symptom resolution following dietary purine restriction and escalation of urate-lowering therapy with allopurinol, achieving sustained low serum uric acid levels. Conclusion: This case highlights an atypical presentation of gout masquerading as recurrent metatarsal stress fractures in the absence of hyperuricemia or classic radiographic findings. Clinicians should maintain a high index of suspicion for gout in patients with episodic, severe foot pain and unexplained stress fractures, as early recognition may prevent unnecessary surgical interventions and prolonged morbidity.