In immunocompromised groups—such as patients with diabetes, dialysis, or an organ transplant— gout and infection can have similar presentations (Dore, 2008). Erythrocyte sedimentation rate (ESR) and Creactive protein (CRP) can be elevated in both, but lack diagnostic specificity. Clinical signs and symptoms may also be unreliable indicators. Chui and Lee found that approximately one-half of the patients with septic arthritis and over one-third of those who develop overlapping septic arthritis and gout will be afebrile on clinical presentation (Chui and Lee, 2007). Therefore, even if crystals have been found previously, aspiration and culture are warranted in the previously stated groups (Simkin, 2008). Urgent referral may be needed if this cannot be done in primary care.