Normal serum uric acid gout: a neglected and challenging condition

During acute gout flares, serum uric acid (SUA) levels may remain within the normal range, making diagnosis based solely on SUA unreliable. A systematic evaluation incorporating clinical symptoms and imaging (ultrasound, dual-source CT) is essential to detect monosodium urate (MSU) crystal deposition. Normal-SUA gout often presents with more pronounced inflammation, fever, elevated white blood cell count and C-reactive protein, and may occur after surgery or hemodialysis. Tophi can appear at typical or atypical sites (e.g., face, neck). No specific treatment guidelines exist, but lowering SUA to <360 μmol/L (6 mg/dl) reduces gout flares and promotes MSU dissolution. Emerging therapies-including anti-IL-1β monoclonal antibodies, NLRP3 inhibitors, uricases, and green tea components-show promise in controlling attacks and dissolving crystals without affecting SUA levels.